Workers' Compensation - Purpose of Employer and Insurer Forms, Rhode Island Department of Labor and Training

Coordination of Retirement Benefits Form DWC-36

This form is completed by the employer, employee and claims administrator to determine the amount of workers' compensation benefits an injured employee will receive, if any, upon retirement. The completed form is sent by the Claim Administrator to the employee and attorney, the employer, and the Division of Workers' Compensation.

Employee's Certificate of Dependency Status Form DWC-04

This form is completed by the employee to confirm their marital status, number of dependents, and federal exemptions. The completed form is sent by the employee to the Claim Administrator who must attach it to the appropriate Agreement when filed with the Division of Workers' Compensation.

Employee's Objection to Wage Transcript Form DWC-31

The employee completes and files this form with the Division of Workers' Compensation to object to the filing of a Wage Transcript (DWC-30) used to reduce or end workers' compensation indemnity benefits.

Employer's First Report of Alleged Occupational Injury or Disease Form DWC-01

Completed by the employer for any work-related injury if that injury requires any medical treatment or if the employee loses full wages for at least three consecutive days. The employer must also report any work-related death. Completing this form is not an admission of liability. A $250 fine may be imposed for failure to report or late reporting.

Itemized Statement of Compensation
Completed by the Claim Administrator within 60 days after the discontinuance or suspension of compensation itemizing all payments made on the claim. This form must be filed with the Division of Workers' Compensation with a copy to the employee and his or her attorney and also to the employer. If it was filed by the insurer, a copy should also be sent to the employer.

Memorandum of Agreement Form DWC-02

Completed by the Claim Administrator. The Memorandum of Agreement is the written agreement which establishes liability and the legal rights throughout the claim.

Mutual Agreement Form DWC-24

Completed by the Claim Administrator and the employee. It is used to amend a Memorandum of Agreement, order, or decree. This can also be used to document an agreement for suitable alternative employment.

Non-Prejudicial Agreement Form DWC-20

Completed by the Claim Administrator. This form is the written agreement allowing payments to be made for a period of not more than 13 weeks without prejudice to any party. Liability is not established.

Nonpayment of Indemnity Benefits OBSOLETE as of 01/03

Notice to Employees Regarding Benefit Check Form DWC-32

This is a notice informing the employee that endorsing their benefit check means that they are qualified to receive benefits and that they must report any earnings. It should be sent to employee by the Claim Administrator at the beginning of the claim or with the first check.

Report of Earnings Form DWC-25

Completed by the Claim Administrator and the employee to report any earnings received by the employee while receiving benefits.

Report of Indemnity Payment Form DWC-22

Completed by the Claim Administrator. It combines the Termination of Benefits under Non-Prejudicial Agreement, Report of Payment, and Report of Payment Supplemental. This form is used to report indemnity payments.

Report of Payment Supplement for Variable Partial Form DWC-22a OBSOLETE Use DWC-22.

Report of Specific Payment Form DWC-51

Completed by the Claim Administrator to report the payment of a specific injury. Specific injuries include disfigurement and loss of use, which is also known as permanent partial disability.

Suspension Agreement and Receipt Form DWC-05

Completed by the Claim Administrator and the employee. This form is the written agreement between parties to suspend indemnity benefits.

Wage Statements
Full Time:    Form DWC-03F
Part Time: Form DWC-03P
Seasonal:    Form DWC-03S

Completed by the employer to calculate the employee's average weekly wage. The completed form is sent by the employer to the Claim Administrator. The employer must attach it to the appropriate Agreement when filed with the Division of Workers' Compensation.

Termination of Benefits - Obsolete Use Form DWC-22

Wage Transcript Form DWC-30

Completed by the Claim Administrator and the employee's current employer. When filed with the Department of Labor and Training, indemnity benefits may be discontinued if this form shows that an employee has returned to work for at least two consecutive weeks earning equal to or in excess of their average weekly wage, not including overtime. This form is generally used when a Suspension Agreement DWC-05 cannot be obtained.

WC Act Summary Poster DWC-08 (English) and DWC-08S (Spanish)

Employers are required to display posters summarizing the major points of the Workers' Compensation Act in conspicuous places where they can be read by workers. The poster is available in English and in Spanish. The employer must complete the poster with the insurer named on the workers' compensation insurance policy and the policy effective date. Fill in the adjusting company name if one is used. You will need Adobe Acrobat Reader Version 4 or higher to display this form.

Notice of Claim of Common Law Rights ("Waiver") Form DWC-11 Revised January, 2002

An employee or corporate officer of an employer covered by the Workers' Compensation Act may choose to waive rights under the Worker' Compensation Act and claim common law rights instead by submitting this form.

Rescind Notice of Claim of Common Law Rights Form DWC-11-R Revised January, 2002

An employee submits this form to rescind a previously filed Notice of Claim of Common Law Rights and so be covered by the Workers' Compensation Act.

Election by Exempt Corporate Officer to Become Subject to Workers' Compensation
Form DWC-11C Revised January, 2002

This form only applies to a person who was appointed a corporate officer between 1/1/1999 and 12/31/2001 and was not previously an employee of the corporation. This form allows only these corporate officers to elect to be covered by the Workers' Compensation Act by filing this form. All other corporate officers are covered by the Workers’ Compensation Act.

Notice of Designation as an Independent Contractor Form DWC-11-IC Revised March, 2006

Filing this form clarifies the relationship between a contractor and the business hiring the contractor. Submitting this form means that the contractor is not an employee of the hiring business for workers' compensation purposes. The contractor is responsible for his own workers' compensation insurance coverage. The hiring business is not responsible to provide workers' compensation coverage for the independent contractor.

Notice of Withdrawal of Designation of Independent Contractor
Form DWC 11-ICR Revised January, 2001

The purpose of this DWC-11-ICR form is to end the relationship between a contractor and the hiring business. Submitting this form means that the contractor is no longer independent of the hiring business named on this form. If the contractor continues to work for this business, the business would be responsible to provide workers' compensation coverage for the contractor.

Notice of Issuance, Cancellation, or Failure to Renew Policies
Insurers are required to notify the Division on issuance, renewal, cancellation, non-renewal, or changes to workers' compensation insurance policies. This information must be reported electronically to the Division's designated vendor for information gathering, NCCI. For more information, please contact The Fraud & Compliance Unit at (401) 462-8100, option 8. To contact NCCI, call (800) 622-4123 or visit their web site at www.ncci.com.

Insurance Coverage Certification for Temporary Employment and Employee Leasing Companies
Form DWC 09 Revised November, 2005

This DWC-09 form is issued by the insurance company, not by the insurance agent, to certify that a temporary or leasing agency has RI workers' compensation insurance coverage. If the temporary or leasing agency does not have RI coverage, the employer using or leasing the temporary employee may be held responsible in the event of a job-related injury to the temporary or leased employee.


	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 4/12/12 MDF
	DLT is an equal opportunity employer/program. Auxiliary aids and services available upon request