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

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Form Title	Form Number	Formats Available	Instructions
Coordination of Retirement Benefits	DWC-36	PFD	Instructions
Employee's Certificate of Dependency Status	DWC-04	PFD \| PFD Fillable \| Excel	Instructions
Employee's Objection to Wage Transcript	DWC-31	PFD	Instructions
Employer's First Report of Alleged Occupational Injury or Disease	DWC-01	PFD \| Excel	Instructions
Insurance Coverage Certification for Temporary Employment and Employee Leasing Companies	DWC-09	PFD	Not available
Insurer Assessment Return	-----	Assessment
Itemized Statement of Compensation	DWC-50	PDF	Instructions
Memorandum of Agreement	DWC-02	PDF	Instructions
Mutual Agreement	DWC-24	PDF	Instructions
Non-Prejudicial Agreement	DWC-20	PDF	Instructions
Notice on Benefit Check	DWC-32	PDF	Not available
Notice on Benefit Check in Spanish	DWC-32S	PDF	Not available
Report of Earnings	DWC-25	PDF	Instructions
Report of Indemnity Payment	DWC-22	PDF	Instructions
Report of Specific Payment	DWC-51	PDF	Instructions
Suspension Agreement and Receipt	DWC-05	PDF	Instructions
Termination of Benefits	DWC-22	PDF	Instructions
Wage Statement: Full Time	DWC-03F	PDF \| Excel \| Auto-Calc	Instructions \| Tips
Wage Statement: Part Time	DWC-03P	PDF \| Excel \| Auto-Calc	Instructions \| Tips
Wage Statement: Seasonal	DWC-03S	PDF \| Excel \| Auto-Calc	Instructions \| Tips
Wage Transcript	DWC-30	PDF	Instructions


	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 2/21/13 MDF
	DLT is an equal opportunity employer/program. Auxiliary aids and services available upon request