Workers' Compensation, RI Dept. of Labor and Training
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Insurer Forms

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Form Title
Form Number
Formats Available
Instructions
Coordination of Retirement Benefits
DWC-36
Employee's Certificate of Dependency Status
DWC-04
Employee's Objection to Wage Transcript
DWC-31
First Report of Injury
DWC-01
Insurance Coverage Certification for Temporary Employment and Employee Leasing Companies
DWC-09
Not available
Insurer Assessment Return
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Itemized Statement of Compensation - Replaced by Subsequent Report of Injury (SROI)
DWC-50
Memorandum of Agreement
DWC-02
Mutual Agreement Revised 1/2014
DWC-24
Non-Prejudicial Agreement Revised 6/2014
DWC-20
Not available
Notice on Benefit Check
DWC-32
Not available
Notice on Benefit Check in Spanish
DWC-32S
Not available
Report of Earnings
DWC-25
Report of Indemnity Payment - Replaced by Subsequent Report of Injury (SROI)
DWC-22
Report of Specific Payment - Replaced by Subsequent Report of Injury (SROI)
DWC-51
Subsequent Report of Injury - Replaced by Subsequent Report of Injury (SROI)
DWC-52
Suspension Agreement and Receipt
DWC-05
Termination of Benefits Revised 1/2014
DWC-21
Wage Statement: Full Time
DWC-03F

Instructions | Tips

Wage Statement: Part Time
DWC-03P
Wage Statement: Seasonal
DWC-03S
Wage Transcript
DWC-30


 
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