NOTICE OF DESIGNATION AS INDEPENDENT CONTRACTOR PURSUANT TO RIGL §28-29-17.1
Independent Contractor Details
* First Name:
* MI:
* Last Name:
* Suffix:
* Address 1:
* Address 2:
* Zip: -
* City:
* State:
* Business Name:
* Date of Birth:
Hiring Entity Details
* Hiring Entity Name:
* FEIN: -
* Address 1:
* Address 2:
* Zip: -
* City:
* State:

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 above. 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.

 *Signature

This form is for purposes of Workers' Compensation only and completion of this form means that you are designated as an Independent Contractor for the named hiring entity and you wish to rescind this designation. Information on this form will be shared within the Dept. of Labor and Training, the RI Division of Taxation and the Internal Revenue Service.

 *Signature


Enter the code shown below:
RI0272