Dwc04 2026

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The document is an Employee's Certificate of Dependency Status form used in Rhode Island to collect necessary information from employees for calculating their workers' compensation rate. It requires the employee to provide personal details, marital status, number of federal exemptions, and information about dependents. The form must be completed and returned to the claim administrator promptly to avoid delays in compensation payments.

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Click ‘Get Form’ to open the dwc04 in the editor.
Begin by entering your Claim Administrator File Number at the top of the form. This number is essential for tracking your claim.
In Section 1, provide your employee information. Enter the last four digits of your Social Security Number, gender, address, phone number, and date of birth.
Section 2 is for claim information. Fill in your employer's name, the insurer's name, their address, injury date, and incapacity date.
For Section 3, indicate your marital status by checking either 'Single' or 'Married'. If married, specify if your spouse works and provide their name.
In Section 4, enter the maximum number of Federal Exemptions you can claim for tax purposes.
Finally, list each dependent in Section 5 with their name, date of birth, relationship to you, and whether they are a full-time student. Don’t forget to sign and date the form before submission.

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Versions	Form popularity	Fillable & printable
2013	4.8 Satisfied (76 Votes)

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Who is exempt from workers compensation insurance California?

Under California Labor Code, Division 4, Part 1, Chapter 2, Section 3352, these workers include the following: Sole Proprietors and business owners (excluding roofers) Business owners. Independent contractors like gig workers.

What is a DWC 3 wage statement in Texas?

A DWC-3 is an Employers Wage Statement form outlined by the Texas Department of Insurance, Division of Workers Compensation (DWC). Texas Mutual uses this form to determine the injured employees average weekly wage and calculate financial assistance for them or their beneficiary.

What does DWC mean in workers comp?

The Division of Workers Compensation (DWC) monitors the administration of workers compensation claims, and provides administrative and judicial services to assist in resolving disputes that arise in connection with claims for workers compensation benefits.