Important Electronic Payment Card (EPC) Update Beginning May 18, 2022, the DLT will be switching to a new vendor for payment cards. Claimants who receive their unemployment insurance or temporary disability insurance payments via EPC will receive a new card in the mail. Please click here for more information.
Forms, Resources, & Publications Apprenticeship Sponsor Registration Register an Apprenticeship Program Checklist New Sponsor Intake Sheet Guide to NAICS - Industry Codes Company Ratio Sheet Education Providers List Apprentice Registration Register an Apprentice Checklist Apprenticeship Agreement (Instructions) Cancel an Apprentice Certify Apprentice Completion Request a New Card with extra time Example of Monthly Record Book for Apprentices Request Reciprocal Approval for Out of State Apprentices Info Sheets and Publications Apprenticeship Credit for prior learning Application for GI Bill benefits How High Schools connect with Apprenticeship Funds for Apprentices American Apprenticeship Quick Start Toolkit Federal Resources Playbook for Registered Apprenticeship Equal Opportunity in Apprenticeship Equal Opportunity Worksheet Equal Opportunity in Apprenticeship Poster Real Jobs Rhode Island Forms and Resources Partnership MOU Tool Kit Real Jobs RI PITCH Application Cover Real Pathway Application Cover RJRI and Real Pathways Budget Template PITCH Patnership Memo Real Jobs Rhode Island PITCH Proposal Real Pathways Rhode Island PITCH Proposal Partnership Portal Participant Enrollment Portal Participant Survey Enrollment Webinar for Partnerships Outcome Reporting Webinar for Partnerships Self-Service Enrollment Guide for Participants Comprehensive Support Service Directory Temporary Disability Insurance For Claimants Forms Direct Deposit Form (en Español) Request a 1099 Form (online submission) Tax Refund Form Medical Instructions Form - You are responsible for your medical form (Español) Publications What workers need to know about TDI Partial Return to Work TCI brochure TCI Fact Sheet For Employers Publications TDI for Employers Brochure For Healthcare Providers Impartial Medical Examiner Impartial Medical Examiner Agreement Application Form W-9 Form Publications TDI for Qualified Healthcare Providers Brochure Unemployment Insurance For Claimants Forms Certify for Weekly Payment Appeal a Decision (online) Direct Deposit Authorization / Cancellation Form Request a 1099 Form Return to Work Form Tuition Waiver (online) Adjudication Questionnaires Change your tax withholding information Request for Dependency Information Publications Benefit Rights UI Guide to Filing a Claim Getting Back to Work After a Trade-Related Layoff For Employers Forms Appeal a Decision (online) Employer/Third Party Change of Address Form (online) Report a New Hire (online) UI Employment Tax Forms Relief of Benefit Charges and Waiting Period Waiver Due to a National Disaster/State of Emergency Adjudication Questionnaires Publications Workshare Brochure Employer Handbook (needs update) Digest of Labor Laws (needs update) Workers' Compensation Claims Forms First Report of Injury An injury must be reported if medical treatment is needed, if the injured worker is unable to earn full wages for at least 3 days, or if the injury is fatal. Injured workers and employers do not send a paper first report to RI DLT. A worker reports an injury to the employer. The employer reports the injury to the claim administrator, which is the insurer or the adjusting company handling the claim. The claim administrator reports electronically to RI DLT. No first report forms are accepted on paper. Indemnity Benefits Start A legal agreement to begin compensation is required unless benefits are paid by court order. Benefits may paid without liability for 13 weeks under a Nonprejudicial Agreement (DWC-20) or with liability under a Memorandum of Agreement (DWC-02). In both cases, a Wage Statement and Dependency Form are required as part of the agreement. Nonprejudicial Agreement Form DWC-20 (without liability, up to 13 weeks) Memorandum of Agreement Form DWC-02 (with liability) Wage Statement Form DWC-03 Certificate of Dependency Form DWC-04 Indemnity Benefits Change, Payment of Disfigurement or Loss of Use A Mutual Agreement is required to change benefits, or to pay disfigurement or loss of use benefits: Mutual Agreement Form DWC-24 Indemnity Benefits Stop A legal document is required when indemnity benefits end. Benefits paid without liability under a Nonprejudicial Agreement may be ended with a Termination of Benefits Form DWC-21. Benefit paid with liability may be ended with a Suspension Agreement and Receipt Form DWC-05 or a Wage Transcript Form DWC-30.An employee may object if benefits are ended by a Wage Transcript. Termination of Benefits Form DWC-21 (without liability) Suspension Agreement and Receipt Form DWC-05 (with liability) Wage Transcript Form DWC-30 Employee Objection to Wage Transcript Form DWC-31 Indemnity Benefits Reduced on Retirement Indemnity benefits may be reduced upon retirement. Coordination of Benefits Form DWC-36 Compensation Benefit Checks Compensation must be paid weekly and by check unless the employee and insurer agree to electronic funds transfer. Claim Administrators must notify employee of duty to report earnings. Notice may be given by sending Notice on Benefit Check Form DWC-32, printing the notice on the check, or including notice in the agreement for electronic funds transfer. Agreement for Electronic Payment of Benefits Form DWC-EB1 Rescission of Agreement for Electronic Payment of Benefits Form DWC-EB2 Notice on Benefit Check Form DWC-32 (Español) Duty to Report Earnings An employee must submit a report of earnings to the claim administrator upon written request. Report of Earnings Form DWC-25 Partial Incapacity Gate When benefits paid under § 28-33-18(d) end at the Partial Incapacity Gate, § 28-35-46.1 requires an Itemized Statement of the total amount of compensation and expenses paid be filed with RI DLT within 60 days of benefits end. ONLY claims closed at the Partial Incapacity Gate require an Itemized Statement. Itemized Statement Form DWC-50 Insurance Coverage and Exemption Forms Insurance Coverage Employers with one or more employees must obtain workers’ compensation insurance coverage. Employers are required to post the name and contact information for their workers’ compensation insurer. Employers must post workers’ compensation insurer name and contact information. Electronic Notice of Insurance Policy through NCCI Insurers are required to notify RI DLT when a workers’ compensation policy is issued or changed WC Act Summary Poster DWC-8 (Español) Temporary Employment and Employee Leasing Companies Insurance Coverage Verification DWC-9 Issued by Insurance Company to all certificate holders. Waiver and Election Notice of Claim of Common Law Rights (DWC-11) Known as a waiver form, the signer waives his rights under the RI Workers’ Compensation Act in order to claim rights under common law. Rescind Notice of Claim of Common Law Rights (DWC-11R) Signer regains rights under the RI Workers’ Compensation Act Election by Exempt Corporate Officer to Become Subject to Workers’ Compensation (DWC-11C) This form only applies to any person who was appointed a corporate officer and was not previously an employee of the corporation. If you believe this is the correct form for you, please call (401) 462-8100 for more information. Self Insurance Forms Application for Approval of Workers' Comp Self-Insurance Program Form RI SI-2 Self-Insured Renewal Application Form RI SI-2a Bond of Employer Authorized to pay Workers' Compensation benefits Directly to Employees or their Dependents Form RI SI 5 Initial Surety Bond Extension Agreement RI DI 5a Bond of Employer Authorized to pay Workers' Compensation benefits Directly to Employees or their Dependents RI SI 5b Former Bond of Employer Authorized to pay Workers' Compensation benefits Directly to Employees or their Dependents RI SI 5c Backdate Standby Letter of Credit Form RI SI 6 Escrow Agreement Form RI SI 7 Trust Agreement Form RI SI 7a Certificate of Deposit Agreement Form RI SI 7b Certification Form RI SI 9 Certification Form RI SI 9a Indemnity Agreement Form RI SI 10 Claim Loss Summary Form RI SI 14a Required Data Fields Claims Listing Form RI SI 14b Calculated Security Requirement Form RI SI 15 Self-Insurance Agreement Form RI SI 17 Self-Insurance Agreement Continuation, Extension, and/or Amendment Form RI SI 17b Electronic Filing Forms EDI Information Independent Contractor Claims Designation of Status as an Independent Contractor This form clarifies the relationship between a contractor and the business hiring the contractor. Submitting this form means that the contractor is not an employee of the hiring business for workers' compensation purposes. The contractor is responsible for his own workers' compensation insurance coverage. The hiring business is not responsible to provide workers' compensation coverage for the independent contractor. Notice of Withdrawal of Designation of Independent Contracto This form ends the relationship between a contractor and the hiring business. Submitting this form means that the contractor is no longer independent of the hiring business named on this form. If the contractor continues to work for this business, the business would be responsible to provide workers' compensation coverage for the contractor. Medical Forms Notification of Claim of Compensable Injury DWC-29 Physician's Notice of Release to Work DWC-27/28 Request for Additional Palliative Care DWC-40 Arrigan Center Patient Forms Physician referal form Record Request Name Change First Appointment Intake Form Customer Satisfaction Survey in English (Español) Uninsured Protection Fund Forms UPF Notice of Claim Form Nonresident Employer Service of Process Agent For Service Designation Publications Education Unit Calculation of Compensation Rate (Español) Employee Information Health and Safety Committees (Español) Medical Services and Treatment (Español) Right to Reinstatement (Español) What Employers Should Know About Workers' Comp (Español) What Medical Providers Should Know about Workers' Comp Workers' Comp Brochure Claims Training: Claim Filing Instructions Claim Reporting Requirements EDI Training RI Dept. of Labor and Training Claim Event Guide EDI Basics for Claim Adjusters External Resources The Occupational Safety & Health Administration The National Institute for Occupational Safety and Health Fraud Unit Initial Information Report Form Report of Earnings Form Notice to Employees Regarding the Effect of Endorsement of Benefit Check What is WC Fraud and How to Prove It Workforce Regulation and Safety Labor Standards Forms Pay Equity Complaint Form Employee Bi-Weekly Pay Application Bi-Weekly Pay Affidavit of Continued Compliance Nonpayment of Wages Complaint Form (Español) Mandatory Overtime (Nurses/Hospitals) Complaint Form Intent to Employ a Minor Form Certification of Age Form for minors 16-17 years of age Special Limited Permit to Work for minors 14-15 years of age Publications Ready to Work? Understanding Rhode Island's Child Labor Laws Brochure (Español) Information Employers Must Post Healthy and Safe Families and Workplaces Act Healthy and Safe Fact Sheet (Español) Do I Qualify? (Español) Occupational Safety Elevator Safety Forms Application for Permit to Install or Modernize Vertical Devices (Español) Application for Exam - Mechanic Installer (Español) Application for a COMPANY License Notice of Decommission Form Request for Initial State Inspection Checklists Electric Elevator Inspection Check List (DLT-L129) Hydraulic Elevator Inspection Check List (DLT-L130) Escalator Inspection Check List (DLT-L133) Wheelchair Lifts, Inclined Wheelchair Lifts and Stairway Chairlifts - ASME A18.1 (DLT-L133) Completed forms may be submitted to: Elevator Unit RI Dept. of Labor and Training Center General Complex P.O. Box 20157 1511 Pontiac Ave. Cranston RI 02920 Fax: (401) 462-8576 Boiler Safety Hot Water Heater Safety Brochure Application for Permit to Install Boilers (Español) Pay For Boiler Installation Permit Right-to-Know Forms Hazardous Substance Right-to-Know Annual Registration Form Hazardous Substance List Alphabetical by CAS Number Right to Know Complaint Form (Español) Annual Registration Form Completed forms may be submitted to: Right to Know Unit RI Dept. of Labor and Training Center General Complex P.O. Box 20157 1511 Pontiac Ave. Cranston RI 02920 Fax: (401) 462-8576 Publications Right to Know Brochure Sara Title III Emergency Planning Community Right to Know Booklet Weights and Measures Petroleum Dealers License Application Form (Español) Prevailing Wage Forms Complaint Form Please note - this form MUST be signed in the presence of a Prevailing Wage Investigator Both forms must be completely filled out. Call (401) 462-8580, option 7 to schedule an appointment Referral Form Please note - this form MUST be signed in the presence of a Prevailing Wage Investigator Both forms must be completely filled out. Certified Weekly Payroll and Statement of Compliance FormInstructions (Español) Certified Prevailing Wage Daily Log Apprenticeship Requirement Complaint Form (Español Awarding Authority Referral Form for Noncompliant Contractors Subcontractor Apprenticeship Certification Form General Contractor Apprenticeship Certification Form General Contractor Apprenticeship Re-Certification and Certification Form *Proposed Prevailing Wage Contract Addendum for State/Quasi *Proposed Prevailing Wage Contract Addendum for Municipalities Conformance Request for Labor Certification Verification of Secretary of State Registration * Any violation of RIGL 37-13-13 of Certified Weekly Payroll Forms and Daily Logs will result in the department imposing a penalty on the contractor of a minimum of one hundred dollars ($100) for each calendar day of noncompliance. Publications Advisory Regarding Payment of Fringe Benefits to Apprentices on Prevailing Wage Projects Notice to Employees working on State/Municipal Financed Construction Projects (Español) Professional Regulation Burglar and Hold-Up Alarm Application for Alarm Business License (en español) Business Renewal for Alarm Business License (en español) Application and Instructions for Alarm Agent License (en español) Renewal for Alarm Agent License (en español) Complaint Form (en español) Bond of Burglar Alarm Business to the General Treasurer Authorization for Background Check and Release (en español) Electrician Electrical Contractor/Corporations Application (en español) Application for a Limited Premise Electrical License (en español) Application for an Electrician's License (en español) Renewable Energy Application and Exemption Form (en español) Company Ratio Sheet Apprentice Completion Hoisting Hoisting Engineer Application (Español) Hoisting Exemption Form Operator Trainee License Application (Español) Health Card - Medical Examination Report for Commercial Driver Fitness Determinations Study Materials for Hoisting Engineers DigSafe Study Guide (Español) CFR 1926 Subpart P (For test code 140, 204, 207) §1926.650 §1926.651 §1926.652 Appendix A Appendix B OSHA eTool study guide (For test code 147, 140) Mechanicals Mechanical Application Form (Español) Mechanical Corporation Apprentice Completion Plumbing Plumbing and Irrigating Application Form (Español) Plumbing Corporation Water Filtration Application Form (Español) Company Ratio Sheet Apprentice Completion Non Indentured Plumbers Apprenticeship Application Non Indentured Plumber Apprentice Information and Checklist Telecommunications Telecommunications Form (Español) Telecommunications Corporate Application Form (Español) Study Guides for Telecommunications Exams Additional Forms Master License Exemption Form 15hr Certificate of Completion Apprentice Completion