Notice Of Withdrawal Of Designation As Independent Contractor
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Notice Of Withdrawal Of Designation As Independent Contractor Form. This is a Rhode Island form and can be use in Department Of Labor And Training Workers Comp.
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Tags: Notice Of Withdrawal Of Designation As Independent Contractor, DWC-11-ICR, Rhode Island Workers Comp, Department Of Labor And Training
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 WITHDRAWAL OF DESIGNATION AS INDEPENDENT CONTRACTOR
PURSUANT TO RIGL §28-29-17.1
* (Name)
Soc. Sec. No.
* Business Name
FEIN
Address
Business License No.
Date of Birth
*hereby withdraw my Designation as Independent Contractor for:
* Hiring Entity Name
* Address
Independent Contractor:
Signature
Date
* This information is available to the public.
The Department will mail a confirmation of this filing to the independent contractor and the
hiring entity within five business days. If you have any questions, call 462-8100, option 5.
DWC-11-ICR (3/06)
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