Form 1 - Employer First Report Of Injury

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Form 1 (Rev. 9/11)
DEPARTMENT OF LABOR – ATTN: WORKERS’ COMPENSATION
(Approved for use as OSHA 101 and 301)
PO Box 488
Montpelier, VT 05601-0488
(802) 828-2286
State File No.
EMPLOYER FIRST REPORT OF INJURY
Answer every question fully and report promptly to avoid a penalty. Employer’s Federal ID Number and Employee Social Security Number MUST be
provided.
1. Legal Name:
2. Business
E
Name:
M
3. Mail Address: No. and Street
City
State
Zip
P
L
4. Location (if different from Mail Address):
5. Telephone Number, Extension and Contact Person.:
O
Y
E
6. Nature of Business (list principal products or service of
7. Do you regularly employ 10 or more
8. Federal ID No.:
R
concern):
employees?
Yes
No
9. Name: First Name
Middle Initial
Last Name
10. Social Security No.:
11. Date of Birth:
E
M
12. Home Address: No. and Street
13. Home Phone No.:
14. Work Phone No:
15. Age:
P
L
City
State
Zip
16. Job Title:
17. Sex:
O
M
F
Y
18. Wages $
Hours Per Day
19. If board, lodging, etc. were
20. Was employee hired in
21. Date of Hire
E
furnished in addition to wages, state
VT?
E
estimated value:
Per
Days Per Week
$
Yes
No
22. Date of Accident:
Accident Time:
Began Shift:
23. Location of Accident: Town or
State
A
City
C
AM
PM
AM
PM
C
24. Machine, tool, object, motor vehicle or substance directly causing injury:
I
D
E
25. On employer’s premises?
Yes
No
If yes, name of department:
N
26. Describe what employee was doing:
Was this the employee’s regular occupation?
Yes
No
T
27. How did accident occur? Describe events leading up to the accident:
28. Describe the injury and the part of the body injured.
29. Was this a first-aid only injury:
I
Yes
No
N
30. Any Lost Time?
If yes, date disability
Last date paid in
31. Employee returned to
If yes, date
Medical Only Incident:
J
began
full:
work?
U
Yes
No
Yes
No
Yes
No
R
Y
32. Did injury result in death?
If yes, date of death.
Yes
No
33. Name and address of Physician:
34. Name and address of Hospital:
Remained Overnight
Yes
No
35. Insurance Company Named on Workers’ Compensation Policy
35A. Claim Administrator
I
N
Name in full:
Company Name
S
Policy No.
Phone Number
Signed by:
Employer or Representative
Title
Date
Equal Opportunity is the Law

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