State of Rhode Island Forms in Word

RI Workers’ Comp Form No.

RI Workers’ Comp Form Title

Employer’s First Report of Alleged Occupational Injury or Disease

Employee’s Objection to Wage Transcript

Wage Statement: Full Time

Wage Statement: Part Time

Wage Statement: Seasonal

Employee’s Certificate of Dependency Status

Election by Exempt Corporate Officer to Become Subject to Workers’ Compensation

Notice of Claim of Common Law Rights (Waiver)

Notice of Designation as an Independent Contractor

Notice of Insurance Policy Change

Notice of Withdrawal of Designation as Independent Contractor

Rescind Notice of Claim of Common Law Rights

WC Act Summary Poster (English)

WC Act Summary Poster (Spanish)

Coordination of Retirement Benefits

Employee’s Certificate of Dependency Status

Employee’s Objection to Wage Transcript

Employer’s First Report of Alleged Occupational Injury or Disease

Insurance Coverage Certification for Temporary Employment and Employee Leasing Companies

Insurer Assessment Return

Itemized Statement of Compensation

Memorandum of Agreement

Mutual Agreement

Non-Prejudicial Agreement

Notice to Employees Regarding Benefit Check

Report of Earnings

Report of Indemnity Payment

Report of Payment Supplement

Report of Specific Payment

Suspension Agreement and Receipt

Termination of Benefits

Wage Statement: Full Time

Wage Statement: Part Time

Wage Statement: Seasonal

Wage Transcript

DWC-29

Notification of Claim of Compensable Injury

DWC-27/28

Physician’s Notice of Release to Work

DWC-40

Request for Additional Palliative Care