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Are Claim Forms Available?

Claim Documents are Available

Claim forms are available on our beaconmutual.com Claims page:

Click here to access the Claim Forms and Other Documents.

  • Full Time Wage Form
    DWC-03F - State of Rhode Island DLT wage form for employees hired for 20 hours or more per week.

  • Part Time Wage Form
    DWC-03P - State of Rhode Island DLT wage form for employees hired for 20 hours or more per week.

  • Certificate of Dependency Status
    DWC-04 - State of Rhode Island form for employees' certificate of dependency status.

  • Physical Job Description Form
    This form used to gather and document key information about the physical demands of the job.

  • Initial Injury Report
    This form is to aid in the gathering of information when a workplace injury occurs.