Self-Insurance and Uninsured Protection Fund

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

Uninsured Protection Fund

• UPF Notice of Claim Form