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

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Form Title	Form Number	Date Revised	Purpose	Instructions	PDF	Excel
Coordination of Retirement Benefits	DWC-36	04/05	Purpose	Instructions	DWC-36	Not available
Employee's Certificate of Dependency Status	DWC-04	01/03	Purpose	Instructions	DWC-04	Not available
Employee's Objection to Wage Transcript	DWC-31	01/03	Purpose	Instructions	DWC-31	Not available
Employer's First Report of Alleged Occupational Injury or Disease	DWC-01	01/03	Purpose	Instructions	DWC-01	DWC-01
Insurance Coverage Certification for Temporary Employment and Employee Leasing Companies	DWC-09	11/05	Purpose	Not available	DWC-09	Not available
Insurer Assessment Return	-----	02/10			Assessment	Not available
Itemized Statement of Compensation	DWC-50	01/03	Purpose	Instructions	DWC-50	Not available
Memorandum of Agreement	DWC-02	01/03	Purpose	Instructions	DWC-02	Not available
Mutual Agreement	DWC-24	01/03	Purpose	Instructions	DWC-24	Not available
Non-Prejudicial Agreement	DWC-20	01/03	Purpose	Instructions	DWC-20	Not available
Notice to Employees Regarding Benefit Check	DWC-32	01/03	Purpose	Not available	DWC-32	Not available
Report of Earnings	DWC-25	01/03	Purpose	Instructions	DWC-25	Not available
Report of Indemnity Payment	DWC-22	01/03	Purpose	Instructions	DWC-22	Not available
Report of Payment Supplement	DWC-22a	OBSOLETE	Info	Use DWC-22	Not available	Not available
Report of Specific Payment	DWC-51	01/03	Purpose	Instructions	DWC-51	Not available
Suspension Agreement and Receipt	DWC-05	01/03	Purpose	Instructions	DWC-05	Not available
Termination of Benefits	DWC-21	OBSOLETE	Info	Use DWC-22	Not available	Not available
Wage Statement: Full Time	DWC-03F	01/03	Purpose	Instructions \| Tips	DWC-03F	DWC-03F
Wage Statement: Part Time	DWC-03P	01/03	Purpose	Instructions \| Tips	DWC-03P	DWC-03P
Wage Statement: Seasonal	DWC-03S	01/03	Purpose	Instructions \| Tips	DWC-03S	DWC-03S
Wage Transcript	DWC-30	01/03	Purpose	Instructions	DWC-30	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 10/28/11 MDF
	DLT is an equal opportunity employer/program. Auxiliary aids and services available upon request