Form 1 - Employee'S Claim And Employer First Report Of Injury - 2000

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STATE OF VERMONT
Form 1
(Rev. 12/00)
(Approved for use as OSHA 101)
DEPARTMENT OF LABOR AND INDUSTRY
Drawer 20
State File No.
Montpelier, VT 05620-3401
EMPLOYEE’ S CLAIM AND EMPLOYER FIRST REPORT OF INJURY
Complete form in ink or typewriter and send original to the Commissioner of Labor and Industry 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:
No. and Street
City
State
Zip
L
4. Location (if different from Mail Address):
O
Federal ID No.
Y
E
5. Nature of Business (list principal products or service of concern):
Do you regularly employ 10 or more
Telephone No.
employees?
R
Yes
No
9. Date of birth:
E
6. Name:
First Name
Middle Initial
Last Name
8. Social Security No.
M
P
7. Home Address:
No. and Street
Telephone No.
10. Job Title:
9A. Age
L
O
City or Town
State
Zip
12. Dept. assigned to:
11. Sex
M
F
Y
E
13. Wages $
Hours Per Day
14. If board, lodging, etc. were furnished in addition to
15. Was employee hired in
16. Date of Hire
wages, state estimated value:
VT?
Per
Days Per Week
E
$
No
Yes
A
17. Date of Accident:
Hour
20.Machine or tool involved in the accident:
a.m.
p.m.
C
18. Location of Accident:
Town or City
State
21. Was it defective?
No
Yes
If yes, describe how.
C
19.On employer’ s premises?
No
Yes
22.Object or substance directly causing injury:
If yes, name of dept.:
I
23. Describe what employee was doing:
Was this the employee’ s regular
occupation?
No
Yes
D
24.How did accident occur? Describe events leading up to the accident.
E
25.Can the employer prevent this type of accident?
No
Yes
If yes, describe how.
N
26. Was safety equipment, such as goggles or guards, etc. provided?
No
Yes
T
27. Could the injured have prevented this type of accident?
No
Yes
If yes, describe how (do not say, “ By being more careful.” ).
28. If safety equipment was provided, was it being used?
No
Yes
I
29. Describe the injury and the part of body injured.
N
J
30. Any Lost Time?
If yes, date disability began.
Last date paid in full:
31. Employee returned to work?
If yes, date returned.
At what weekly wage:
No
Yes
No
Yes
$
U
R
32.Did injury result in death?
If yes, date of death.
33. If death, name and address of nearest relative.
Relationship
Y
No
Yes
34. Name and Address of Physician
35. Name and Address of Hospital
I
36.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
____ Labor & Industry
____ Ins. Co.
____Employer
____Employee

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