Form 1
(Rev. 7/08)
(Approved for use as OSHA 101 and 301)
DEPARTMENT OF LABOR – ATTN: WORKERS’ COMPENSATION
5 Green Mountain Drive, PO Box 488
Montpelier, VT 05601-0488
State File No.
EMPLOYEE’S CLAIM AND EMPLOYER FIRST REPORT OF INJURY
Complete form and send original to the Commissioner of Labor within 72 hours of accident. Send duplicate to your workers’ compensation insurance company, give Employee’s copy to
employee and retain Employer’s copy for your files. Answer every question fully and report promptly to avoid a penalty. Employer’s Federal ID Number and Employee’s Social Security
Number MUST be provided.
E
1.Legal Name:
2.Business Name:
M
P
3. Mail Address:
City
State
Zip
No. and Street
L
O
4. Location (if different from Mail Address):
5. Federal ID No.
Y
E
6. Nature of Business (list principal products or service of concern):
7. Do you regularly employ 10 or more
8. Telephone No.
employees?
R
Yes
No
11. Date of birth:
E
9. Name:
First Name
Middle Initial
Last Name
10. Social Security No.
M
12. Home Address:
No. and Street
14. Job Title:
P
13. Telephone No.
15. Age
L
O
City
State
Zip
16. Dept. assigned to:
17. Sex
Y
M
F
E
19. If board, lodging, etc. were furnished in
20. Was employee hired in VT?
21. Date of Hire
18. Wages $
Hours Per Day
addition to wages, state estimated value:
E
No
Yes
Per
Days Per Week
$
A
22. Date of Accident:
Accident Time
Began Shift
23.Machine or tool involved in the accident:
a.m.
p.m.
a.m.
p.m.
C
24. Location of Accident:
Town or City
State
25. Was it defective?
No
Yes
If yes, describe how.
C
26.On employer’s premises?
No
Yes
27.Object or substance directly causing injury:
If yes, name of dept.:
I
Was this the employee’s regular
28. Describe what employee was doing:
occupation?
No
Yes
D
29. How did accident occur? Describe events leading up to the accident.
E
30. Can the employer prevent this type of accident?
No
Yes
If yes, describe how.
N
31. Was safety equipment, such as goggles or guards, etc. provided?
No
Yes
T
32. Could the injured have prevented this type of accident?
No
Yes
If yes, describe how (do not say, “By being more careful.”).
33. If safety equipment was provided, was it being used?
No
Yes
I
34. Describe the injury and the part of body injured.
35. Was this a first-aid only injury:
Yes
No
N
J
36. Any Lost Time?
If yes, date disability
Last date paid in full:
37. Employee returned to
If yes, date returned.
At what weekly
began.
work?
wage:
No
Yes
U
No
Yes
$
R
38.Did injury result in
If yes, date of death.
39. If death, name and address of nearest relative.
Relationship
death?
Y
No
Yes
40. Name and Address of Physician
Remained overnight? Yes
No
41. Name and Address of Hospital
I
42.Workers’ Compensation Insurance Carrier. Do NOT give your insurance agent’s name.
N
S
Name in full:
Policy No.
Signed by:
Employer or Representative
Title
Date
____Provided Form 8
____ Dept. of Labor
____ Ins. Co.
____Employer
____Employee
Equal Opportunity is the Law