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APPLICATION FOR DEALERS LICENSE

STATE OF RHODE ISLAND ‐‐ DIVISION OF MOTOR VEHICLES Dealer Section 600 New London Avenue ,Cranston, RI 02920-3024 www.dmv.ri.gov

WORKERS’ COMPENSATION INSURANCE REQUIREMENTS

Corporate Name:

________________________________________________________

d/b/a Name:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Employees not listed on this form require a waiver from Workers’ Compensation.

LIST ALL EMPLOYEES PROTECTED BY WORKERS’ COMPENSATION INSURANCE COVERAGE BOTH SOCIAL SECURITY AND DRIVERS LICENSE NUMBERS ARE REQUIRED.

Name:

__________________________________________________Drivers License#

__________________

Name:

__________________________________________________Drivers License#

__________________

Name:

__________________________________________________Drivers License#

__________________

Name:

__________________________________________________Drivers License#

__________________

TOTAL NUMBER OF EMPLOYEES LISTED:____________________________________ Please notify this office of any changes to this list as they occur.

Name:

Drivers License#

__________________________________________________

__________________

All Rhode Island employers with one or more employees are required to obtain worker compensation insurance coverage. This includes both full time and part time workers. Sole proprietors, partners, members of limited liability companies and independent contractors are not included. Most corporate officers are included when determining coverage requirements. Employees, including corporate officers, may exclude themselves from coverage by filing a DWC-11 form with the Department of Labor and Training, Division of Workers’ Compensation. Some exemptions to the insurance coverage requirement are, domestic servants, some farmers and farm laborers, some arborists and nursery personnel and certain real estate persons. The penalty for failure to provide workers’ compensation insurance is up to $500 to $1000 per day of non- compliance. The Director of the Department of Labor and Training may close a business for a failure to provide workers’ compensation insurance. Knowing failure to provide workers’ compensation insurance may result in a felony charge with imprisonment of up to two (2) years and/or a fine of $10,000. For further information on compliance and enforcement, please contact (401) 462-8100 and press option #8, or contact and Education Unit Representative at the same number but choose option #1.

State of Rhode Island County:_______________

_______________________________________ Signature of Owner, Partner or Corporate Office

Subscribed and sworn to before me this

_______day of

20

_____________ _____

________________________________ Notary Public DLR013 – DATED 08-25-10

______________________________ Commission Expires

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