Claims Filing
To access Trust claim forms, click the appropriate link below.

Workers' Compensation Claims Filing
You can contact the Claims Department at (401) 438-6511.

Following are descriptions of the various forms that are used in filing workers' compensation claims. Click the link to the Department of Labor & Training's web site above to access the necessary form. After completion, the form(s) should be printed and forwarded to The Trust either by mail or by fax.

Please note that a workers' compensation claim is not considered to be officially reported until it is signed by the employer and physically received by the Department of Labor, Workers' Compensation Division.

First Report of Injury Form
Description/Use
When an injury either requires medical treatment or results in an incapacity of 3 consecutive days, State law requires the employer to report it to the Division of Workers' Compensation within 10 days of the injury. Fatal injuries must be reported within 48 hours of death. Filing the First Report does not admit liability. There is a penalty of $250 for failure to file the First Report of Injury. The injury should be reported to both the Division of Workers' Compensation and the Rhode Island Interlocal Risk Management Trust.

Download First Report of Injury
(right click and select "Save Target As..." from the menu)
OR
Open First Report of Injury in a new window.
Dependency Form
Description/Use
This form shows the injured worker's number of dependents and federal exemptions. The injured worker completes this form and forwards it to the employer or insurer. The Trust sends the Dependency Form to the Division of Workers' Compensation with the appropriate filings.

Download Dependency Form
(right click and select "Save Target As..." from the menu)
OR
Open Dependency Form in a new window.
Wage Statement
Description/Use
The employer completes the wage statement and forwards it to the Rhode Island Interlocal Risk Management Trust. The Trust uses the wage information to calculate the injured worker's compensation rate.

Download Wage Statement
(right click and select "Save Target As..." from the menu)
OR
Open Wage Statement in a new window. Mail or Fax completed forms to:
Claims Department The Trust 501 Wampanoag Trail, Suite 301 East Providence, RI 02915
Claims Fax: 401-434-6094

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Public Service Injured-on-Duty
Members who are eligible for the Trust's Public Service Injured-on-Duty (IOD) Program (municipal Members who belong to the Workers' Compensation Pool) should report on-the-job injuries for their public safety employees using the Employer's First Report of Injury for Public Safety Employees form. This report will advise The Trust about the nature of the injury, whether any time was lost from work, and whether medical treatment was received. This form should be signed by the employee's supervisor and forwarded to The Trust either by fax at (401) 434-6094 or by mail.

Download IOD First Report of Injury
(right click and select "Save Target As..." from the menu)
OR
Open IOD First Report of Injury in a new window. Click here to complete form: Employer's First Report of Injury for Public Safety IOD Employees.

Also included below is a step-by-step instruction sheet on how to process an IOD Claim. Please note that this particular form was designed for Members with Blue Cross/Blue Shield Health Coverage. If your entity does not have Blue Cross/Blue Shield coverage, please contact Liz Carr at lcarr@ritrust.com or 438-6511, ext. 533.

Download How to Process IOD CLaims.pdf
(right click and select "Save Target As..." from the menu)
OR
Open .pdf in a new window. Click here to complete form: Employer's First Report of Injury for Public Safety IOD Employees.

Also included below is a step-by-step instruction sheet on how to process an IOD Claim. Please note that this particular form was designed for Members with Blue Cross/Blue Shield Health Coverage. If your entity does not have Blue Cross/Blue Shield coverage, please contact Liz Carr at lcarr@ritrust.com or 438-6511, ext. 533.

Download How to Process IOD CLaims.pdf
(right click and select "Save Target As..." from the menu)
OR
Open .pdf in a new window. Department of Labor Web Site

General Liability - Property - Auto Liability and/or Collision Claims Filing
Liability and property claims, or incidents likely to give rise to a claim, should be reported to The Trust. Please complete claim forms to the best of your ability based on the information available to you. Supplement the forms as necessary with any additional information you believe may be of value to the investigation of the claim.
Forward one copy to The Trust's Claim Department, and retain one copy for your records. Claims can be submitted by mail, by e-mail, or by fax to Russ Godin, Assistant Claims Manager for Property and Liability.

Liability Claims
Liability claims alleging bodily injury and all lawsuits should be reported to The Trust immediately, even if the dollar amount appears to be under your deductible.
If you are served with a lawsuit, clearly a claim has been made. As always, if you are not sure if an incident should be reported, contact The Trust. The sooner you can let The Trust know about the incident, irrespective of whether or not it eventually gives rise to a claim, the better planned our defense of your claim can be.
Automobile Liability Claim Form Click here to complete form

General Liability Claim Form Click here to complete form

Property Claims
Prompt reporting is also essential when any Trust Member has a property loss in excess of the deductible. Information about property losses should be telephoned in to The Trust, and then sent by mail using the Property Claims Notice form. All property claims over the deductible amount, whether to your property or to another party's property (e.g. when a Town vehicle strikes the vehicle of someone else), should be reported as soon as possible. The Trust is responsible for adjusting and paying these types of claims and then billing you for the amount paid up to the deductible level. Along with the Property Claim Form, a Sworn Statement in Proof of Loss Form must be completed. That form can also be downloaded below.
Property Claim Form Click here to complete form

Download Sworn Statement in Proof of Loss.pdf
(right click and select "Save Target As..." from the menu)
OR
Open .pdf in a new window.
Please note that in the event a Formal Claim results in a cost below the deductible level, a $250 claims handling fee will apply.
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