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Self-Insurance Forms

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Form Title
Form Number
Formats Available
Instructions
Application for Approval of Workers' Comp Self-Insurance Program RI SI-2 PDF Not Available
Self-Insured Renewal Application RI SI-2a PDF Not Available
Bond of Employer Authorized to pay Workers' Compenstion benefits Directly to Employees or their Dependents RI SI 5
Initial
PDF Not Available

Surety Bond Extension Agreement

RI SI 5a PDF Not Available

Bond of Employer Authorized to pay Workers' Compenstion benefits Directly to Employees or their Dependents

RI SI 5b Former PDF Not Available

Bond of Employer Authorized to pay Workers' Compenstion benefits Directly to Employees or their Dependents

RI SI 5c Backdate PDF Not Available
Standby Letter of Credit RI SI 6 PDF Not Available
Escrow Agreement RI SI 7 PDF Not Available
Trust Agreement RI SI 7a PDF Not Available
Certificate of Deposit Agreement RI SI 7b PDF Not Available
Certificate RI SI 9 PDF Not Available
Certificate RI SI 9a PDF Not Available
Indemnity Agreement RI SI 10 PDF Not Available
Claims Loss Summary RI SI 14a PDF Not Available
Required Data Fields Claims Listing RI SI 14b PDF Not Available
Calculated Security Requirement RI SI 15 PDF Not Available
Self-Insurance Agreement RI SI-17 PDF Not Available
Self Insurance Agreement Continuation, Extension and/or Amendment RI SI 17b 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
5/16/17 MDF
State Seal
  DLT is an equal opportunity employer/program. Auxiliary aids and services available upon request