Workers' Compensation, RI Dept. of Labor and Training
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File a Claim
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Employer Forms

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Form Title
Form Number
Formats Available
Instructions
First Report of Injury
DWC-01
Employer: Report Injury to Your Insurer
Employers must report injuries directly to their workers’ compensation insurance companies.  Insurers must report electronically to State of RI via EDI
Employee's Objection to Wage Transcript
DWC-31
Wage Statement: Full Time
DWC-03F
Wage Statement: Part Time
DWC-03P
Wage Statement: Seasonal
DWC-03S
Employee's Certificate of Dependency Status
DWC-04
Notice of Claim of Common Law Rights (Waiver)
DWC-11
Not Available
Notice of Designation as an Independent Contractor
DWC-11-IC
Not Available
Notice of Insurance Policy Change
PC1 PC2
Electronic Submission Only
Contact NCCI
Notice of Withdrawal of Designation as Independent Contractor
DWC-11-ICR
Not Available
Rescind Notice of Claim of Common Law Rights
DWC-11R
Not Available
WC Act Summary Poster (English)
DWC-08
Not Available
DWC-08S
Not Available
Election by Exempt Corporate Officer to Become Subject to Workers' Compensation
DWC-11C
Not Available,
call (401) 462-8100 option 7 for information.
Self Insurance Forms      
Application for Approval of Workers' Comp Self-Insurance Program RI SI-2 PDF Not Available
Self-Insurance Agreement RI SI-17 PDF Not Available


 
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
4/10/15 MDF
State Seal
  DLT is an equal opportunity employer/program. Auxiliary aids and services available upon request