State of Rhode Island, Department of Labor and Training, Division of Workers’ Compensation P.O. Box 20190, Cranston, RI 02920-0942 Phone (401) 462-8100 TDD (401) 462-8084 www.dlt.ri.gov NOTICE OF DESIGNATION AS INDEPENDENT CONTRACTOR PURSUANT TO RIGL §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 Business License No. Address Date of Birth I declare that I am an independent contractor pursuant to RIGL §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. FEIN * Address Business License No. 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 RI Division of Taxation. Information on this form will be shared within the Dept. of Labor and Training, the RI 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 RIGL §28-33-17.3. * This information is available to the public including the Hiring Entity’s Workers’ Compensation Insurance Carrier. The Department will mail a confirmation of this filing to the independent contractor within five business days. If you have any questions, call 462-8100, option 5. DWC-11-IC (3/2006) American LegalNet, Inc. www.USCourtForms.com DWC-11-IC Reverse Side This is a form DWC11-IC, Designation of Independent Contractor. This means that you have stated that you are an independent contractor NOT an employee and are NOT eligible for Workers’ Compensation benefits. Many factors are considered when determining whether someone is an employee or an independent contractor. Some of those factors are: independent contractors set their own work hours, have their own tools and work when and for whom they choose. An employer generally does not have to withhold or pay any taxes on payment to independent contractors, such as social security, Medicare, unemployment and Temporary Disability Insurance (TDI). This form is for purposes of Workers’ Compensation, and completion of this form does not mean that you are considered an Independent Contractor under the rules, regulations or statutes of the Internal Revenue Service or the R.I. Division of Taxation. SHOULD YOU HAVE ANY QUESTIONS ABOUT WHETHER YOU ARE AN INDEPENDENT CONTRACTOR OR AN EMPLOYEE, PLEASE CONTACT THE RI DIVISION OF TAXATION AT (401) 222-3682, OR THE US GOVERNMENT INTERNAL REVENUE SERVICE AT 800-829-1040. IF YOU FEEL YOU HAVE BEEN COERCED OR FORCED TO SIGN THE INDEPENDENT CONTRACTOR FORM, REPORT THIS TO THE WORKERS’ COMPENSATION FRAUD AND COMPLIANCE UNIT AT (401) 462-8100, option 7. When your work as an independent contractor ends with this employer, complete and return the form titled Notice of Withdrawal of Designation as Independent Contractor , DWC-11-ICR, to the Dept. of Labor and Training, Division of Workers’ Compensation. If you have a question, contact the Division of Workers’ Compensation at (401) 462-8100, option 5. For further information, contact the Workers’ Compensation Information Line at (401) 462-8100, option 1. DWC-11-IC (3/2006) Side 2 American LegalNet, Inc. www.USCourtForms.com