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Claims Forms

 

General Instructions: RI requires that both legal documents and electronic EDI transactions be filed over the duration of a claim. 

  • Legal agreement documents are submitted on paper. The forms and instructions are below, with a brief explanation of when each form is used. The document, Claim Filing Instructions, explains legal document filing requirements in more detail.

  • Notices are submitted electronically. See EDI Transaction Information for more information on electronic filings.


First Report of Injury

An injury must be reported if medical treatment is needed, if the injured worker is unable to earn full wages for at least 3 days, or if the injury is fatal.

  • Injured workers and employers do not send a paper first report to RI DLT.  A worker reports an injury to the employer.  The employer reports the injury to the claim administrator, which is the insurer or the adjusting company handling the claim.  The claim administrator reports electronically to RI DLT.  No first report forms are accepted on paper. Visit the RI DLT EDI web page for more information. 

Indemnity Benefits Start: A legal agreement to begin compensation is required unless benefits are paid by court order.  Benefits may paid without liability for 13 weeks under a Nonprejudicial Agreement (DWC-20) or with liability under a Memorandum of Agreement (DWC-02). In both cases, a Wage Statement and Dependency Form are required as part of the agreement.

Indemnity Benefits Change, Payment of Disfigurement or Loss of Use:  A Mutual Agreement is required to change benefits, or to pay disfigurement or loss of use benefits:

Indemnity Benefits Stop: A legal document is required when indemnity benefits end.  Benefits paid without liability under a Nonprejudicial Agreement may be ended with a Termination of Benefits Form DWC-21. Benefit paid with liability may be ended with a Suspension Agreement and Receipt Form DWC-05 or a Wage Transcript Form DWC-30. An employee may object if benefits are ended by a Wage Transcript.

Indemnity Benefits Reduced on Retirement: Indemnity benefits may be reduced upon retirement.

Compensation Benefit Checks: Compensation must be paid weekly and by check unless the employee and insurer agree to electronic funds transfer. Claim Administrators must notify employee of duty to report earnings. Notice may be given by sending Notice on Benefit Check Form DWC-32, printing the notice on the check, or including notice in the agreement for electronic funds transfer.

Duty to Report Earnings: An employee must submit a report of earnings to the claim administrator upon written request.

Partial Incapacity Gate: When benefits paid under § 28-33-18(d) end at the Partial Incapacity Gate, § 28-35-46.1 requires an Itemized Statement of the total amount of compensation and expenses paid be filed with RI DLT within 60 days of benefits end.  ONLY claims closed at the Partial Incapacity Gate require an Itemized Statement.

Disputes: The RI Workers’ Compensation Court handles disputes. 

 
RI Department of Labor and Training
Workers' Compensation
Center General Complex
1511 Pontiac Avenue, Cranston, RI 02920


Phone: (401) 462-8100
Fax (401) 462-8105
TTY via RI Relay: 711
7/10/17 MDF
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  DLT is an equal opportunity employer/program. Auxiliary aids and services available upon request