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