STATE OF RHODE ISLAND DEPARTMENT OF LABOR & TRAINING, DIVISION OF WORKERS' COMPENSATION PO BOX 20190, CRANSTON RI 02920 Phone (401) 462-8100 TDD (401) 462-8006 RHODE ISLAND WORKERS' COMPENSATION INSURANCE COVERAGE CERTIFICATION For Temporary Employment and Employee Leasing Companies CERTIFICATE HOLDER INSURED EMPLOYER USING OR LEASING TEMPORARY EMPLOYEES TEMPORARY OR LEASING AGENCY This certificate is issued by the insurer (not an agent) pursuant to RIGL §28-29-2. An employer that uses leased or temporary employees must obtain this certificate showing that the temporary or leasing agency has RI workers' compensation insurance coverage. If the temporary or leasing agency does not have RI coverage, the employer using or leasing the temporary employee may be held responsible in the event of a job-related injury to the temporary or leased employee. COVERAGES This is to certify that a policy of insurance listed below has been issued to the insured named above for the policy period indicated. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate may be issued or may pertain, the insurance afforded by the policies described herein is subject to all the terms, exclusions, and conditions of such policies. TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE POLICY EXPIRATION DATE STATE OF COVERAGE CANCELLATION Should the above policy be cancelled before the expiration date or not be renewed, the insurance carrier named below shall provide written notice to the certificate holder named herein. Insurance Carrier: Prepared By: Date Issued: Print Name of Insurer Employee ****THIS CERTIFICATION IS NOT VALID UNLESS ISSUED BY THE INSURANCE CARRIER NAMED ABOVE**** ***AGENTS CANNOT ISSUE THIS CERTIFICATION*** DWC-09 (11/05) American LegalNet, Inc. www.USCourtForms.com