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

Coordination of Retirement Benefits Form DWC-36

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

Employee's Certificate of Dependency Status Form DWC-04

The employee completes the dependency form to confirm marital status, number of dependents, and federal exemptions so that the compensation rate can be accurately calculated. The employee returns the completed form to the Claim Administrator. The Claims Administrator must include the dependency form when filing a Non-Prejudicial Agreement or Memorandum of Agreement with the Division of Workers' Compensation.

Employee's Objection to Wage Transcript Form DWC-31

The employee files this form with the Division of Workers' Compensation to object to a Wage Transcript (DWC-30). A Wage Transcript reduces or ends workers' compensation indemnity benefits.

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

The employer must file a first report for any work-related injury requiring 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. The Claims Administrator may file the First Report on behalf of the employer.

Itemized Statement of Compensation Form DWC-50

The Claim Administrator files this form within 60 days after indemnity benefits end to summarize payments made on indemnity claims.

Memorandum of Agreement Form DWC-02

The Memorandum of Agreement is the legal authorization for compensation. It establishes liability and the legal rights throughout the claim. The Claim Administrator completes this form and files it with the Division of Workers' Compensation.

Mutual Agreement Form DWC-24

The Claim Administrator and the employee complete the Mutual Agreement 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

The Non-Prejudicial Agreement is the legal authorization to begin compensation without establishing liability. Benefits may be paid for up to 13 weeks without liability. The Claim Administrator completes this form and files it with the Division of Workers' Compensation.

Nonpayment of Indemnity Benefits OBSOLETE as of 01/03

Notice to Employees Regarding Benefit Check Form DWC-32

This is a notice informing employees that endorsing their benefit check means that they are qualified to receive benefits and that they must report any earnings. The Claim Administrator should send the notice to employees at the beginning of the claim or with the first check. This form is also available in Spanish.

Report of Earnings Form DWC-25

This form is used to report any amount the employee earns while receiving workers' compensation benefits. The amount of benefits due to the employee may be adjusted based on earnings. The employee completes this form and sends it to the Claim Administrator.

Report of Indemnity Payment Form DWC-22

The DWC-22 is a multi-purpose form for reporting the details of indemnity benefits.

As a Termination of Benefits: For a benefits paid under a Non-Prejudicial Agreement (without liability), the Claim Administrator files the form when weekly indemnity benefits end. Check "Termination of Benefits". The Termination of Benefits is the legal authorization to end benefits paid under a Non-Prejudicial Agreement.

As a Report of Indemnity Payment: For benefits paid with liability, check "Payment under Memo of Agreement, Order or Decree". For continuing benefits, check "INTERIM". Check "FINAL" when weekly indemnity benefits end. A legal authorization to end benefits is also required when benefits end: Suspension Agreement, Wage Transcript, Court Order or Decree.

Report of Specific Payment Form DWC-51

The Claim Administrator completes this form 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

This form is the written agreement between parties to suspend indemnity benefits paid under Memorandum of Agreement, Court Order, or Decree. The Claim Administrator and the employee must sign and date this form.

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

The employer fills out the wage statement and sends it to the Claims Administrator to calculate the employee's average weekly wage and compensation rate. The Claim Administrator must attach it to the Non-Prejudicial Agreement or Memorandum of Agreement to be filed with the Division of Workers' Compensation.

Termination of Benefits Form DWC-22

The DWC-22 is a multi-purpose form for reporting the details of indemnity benefits.

As a Termination of Benefits: For a benefits paid under a Non-Prejudicial Agreement (without liability), the Claim Administrator files the form when weekly indemnity benefits end. Check "Termination of Benefits". The Termination of Benefits is the legal authorization to end benefits paid under a Non-Prejudicial Agreement.

As a Report of Indemnity Payment: For benefits paid with liability, check "Payment under Memo of Agreement, Order or Decree". For continuing benefits, check "INTERIM". Check "FINAL" when weekly indemnity benefits end. A legal authorization to end benefits is also required when benefits end: Suspension Agreement, Wage Transcript, Court Order or Decree.

Wage Transcript Form DWC-30

This form is the legal authority to end benefits in place of a Suspension Agreement (DWC-05). The form must show the employee returned to work for two consecutive weeks and earned as much or more than the average weekly wage.

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 submit this form to waive rights under the Worker' Compensation Act and claim common law rights instead.

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 2/13/13 MDF
	DLT is an equal opportunity employer/program. Auxiliary aids and services available upon request