Get the free DWC 04 DF - Rhode Island Department of Labor and Training - RI.gov

State of Rhode Island PLEASE CHECK IF CORRECTION OF PRIOR REPORT EMPLOYEE'S CERTIFICATE OF DEPENDENCY STATUS Department of Labor and Training, Division of Workers' Compensation DWC No. Phone (401)

How to fill out dwc 04 df

How to fill out DWC 04 DF:

1. Begin by obtaining the DWC 04 DF form. You can typically find this form on the official website of your state's Division of Workers' Compensation or by contacting your employer's workers' compensation representative.
2. Read the instructions carefully. The instructions provided with the DWC 04 DF form will guide you through the process of filling it out accurately.
3. Start by entering your personal information. This typically includes your full name, address, contact information, and social security number.
4. Provide information about your employer. This may include the company's name, address, and any other relevant details.
5. If you were injured at work, describe how the injury occurred. Include details about the date, time, and location of the incident. Be as specific as possible to paint a clear picture of what happened.
6. Indicate the body parts that were injured. Use the provided checkboxes or write them down manually.
7. Provide information about your medical treatment. This may include the name and contact information of the medical provider who treated you, the dates of treatment, and any medical procedures or medications that were administered to you.
8. If you missed work due to the injury, provide details about your lost time and wages. This may include the dates you were unable to work, the number of hours or days missed, and any wages or income you lost as a result.
9. If you have any witnesses who can support your claim, provide their contact information. Witnesses may include coworkers or others who saw the incident or were aware of your injuries.
10. Review the completed form for any errors or omissions. Make sure all the required fields are filled out, and verify that the information provided is accurate.
11. Sign and date the form. By signing the DWC 04 DF, you are affirming that the information you provided is true and accurate to the best of your knowledge.
12. Keep a copy of the completed form for your records.
13. Submit the DWC 04 DF form as instructed. This may involve sending it to your employer's workers' compensation representative or directly to your state's Division of Workers' Compensation office.

Who needs DWC 04 DF:

1. Employees who have been injured on the job and wish to file a workers' compensation claim.
2. Employers who need to document and report workplace injuries to their workers' compensation provider or state agency.
3. Medical providers who have treated patients for work-related injuries and need to complete the necessary paperwork for workers' compensation claims.

Note: The specific requirements for filing a DWC 04 DF form may vary depending on your state's regulations and the policies of your employer or workers' compensation provider. It is always recommended to consult the official guidelines and seek professional advice if you have any questions or concerns about filling out this form correctly.

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