Your First Name:   Type of Assistance Needed: Last 4 digits of your Social Security Number: Your Last Name: Telephone Number (401-999-9999) - Home:       Email Address:   Cell:    


If you need to complete one of the following options, please visit our website at  
or click on the links below: ■ File a new claim, refile/reopen an existing claim, or file for extended benefits at:


■ Request a 1099G tax form at: ○

■ Update your address at: ○ ■ Delete or update your PIN at: ○ Helpful Information:

Contact Information: Your request will be handled in the order in which it is received. Please do not send duplicate requests as this will only delay the process.

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