Employee'S Claim And Employer First Report Of Injury Form - Vermont

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