Form Dwc-11-Ic - Notice Of Designation As An Independent Contractor - State Of Rhode Island Department Of Labor And Training Page 2

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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 R.I.
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 PREVENTION UNIT AT (401) 462-
8110.
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 Department of Labor &
Training, Workers’ Compensation Unit.
If you have a question, contact the Workers’ Compensation Unit at (401)
462-8081.
For further information, contact the Workers’ Compensation
Information Line at (401) 462-8125.
DWC-11-IC (12-02))

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