State of Rhode Island, Department of Labor and Training, Workers’ Compensation Unit
P.O. Box 20190, Cranston, RI 02920-0942
Phone (401) 462-8100 TDD (401) 462-8006
NOTICE OF DESIGNATION AS INDEPENDENT CONTRACTOR PURSUANT TO R.I.G.L. §28-29-17.1
PLEASE READ OTHER SIDE
WARNING
No one can force you to sign this form. When you sign this form you are stating that you are an
independent contractor and in the event of injury, are not entitled to workers’ compensation
benefits.
*(Name) _______________________________________
Soc. Sec. No. _____________________________________
* Business Name _______________________________
FEIN
__________________________________________
* Address _____________________________________
Business License No. ______________________________
______________________________________________
Date of Birth ______________________________________
I declare that I am an independent contractor pursuant to R.I.G.L. §28-29-17.1 and, therefore, I am not eligible
for nor entitled to Workers’ Compensation benefits pursuant to Title 28, Chapters 29-38, of the Workers’
Compensation Act of the State of Rhode Island for injuries sustained while working as an independent
contractor for the hiring entity named below. This designation will remain in effect while performing services for
the named hiring entity or until a withdrawal of designation as independent contractor form is filed with the
Department of Labor and Training.
* Hiring Entity Name______________________________
Soc. Sec. No. ___________________________________
* Address ______________________________________
FEIN __________________________________________
______________________________________
Bus. License
___________________________________
Warning
! This form is for purposes of Workers’ Compensation only and completion of this form does
not mean that you are an Independent Contractor under the rules, regulations or statutes of the Internal
Revenue Service or the R. I. Division of Taxation. Information on this form will be shared within the
Department of Labor and Training, the R. I. Division of Taxation and the Internal Revenue Service.
Independent Contractor: ____________________________________________________________________
Signature
Date
A hiring entity that knowingly assists, aids and abets, solicits, conspires with or coerces an employee to
misrepresent the employee’s status as an independent contractor may be subject to criminal prosecution under
Rhode Island General Law §28-33-17.3.
* This information is available to the public including the Hiring Entity’s Workers’ Compensation
Insurance Carrier.
FORM IS NOT VALID UNTIL RECEIVED AND DATE STAMPED BY THIS DEPARTMENT.
For a dated receipt copy, include a copy with the original sent to the Department of Labor and Training with a SELF-
ADDRESSED STAMPED ENVELOPE. The original and copy will be date stamped. The original will be retained for our
files. The stamped copy will be returned in the envelope provided.
DWC-11-IC (12-02))
1
2
