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Get Vt 1st Injury 2011-2024

DEPARTMENT OF LABOR ATTN WORKERS COMPENSATION PO Box 488 Montpelier VT 05601-0488 802 828-2286 Form 1 Rev. 9/11 Approved for use as OSHA 101 and 301 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 E M P L O Y R 2. Business Name 3. Mail Address No* and Street 4. Location if different from Mail Address Zip 5. Telephone Number Extension and Contact Person* 7. Do you regularly employ 10 or more 8. Federal ID No* employees Yes No Last Name 10. Social Security No* 11. Date of Birth Middle Initial 12. Home Address No* and Street 13. Home Phone No* City State 18. Wages Hours Per Day Per 22. Date of Accident A C I D N T 6. Nature of Business list principal products or service of concern 9. Name First Name Days Per Week Accident Time AM PM 14. Work Phone No 16. Job Title 15. Age 17. Sex F 20. Was employee hired in 21. Date of Hire VT 19. If board lodging etc* were furnished in addition to wages state estimated value Began Shift 23. Location of Accident Town or 24. Machine tool object motor vehicle or substance directly causing injury 25. On employer s premises 26. Describe what employee was doing If yes name of department Was this the employee s regular occupation 27. How did accident occur Describe events leading up to the accident 28. Describe the injury and the part of the body injured* J U 30. Any Lost Time If yes date disability began 29. Was this a first-aid only injury Last date paid in full 32. Did injury result in death 33. Name and address of Physician 31. Employee returned to work Medical Only Incident If yes date of death. Remained Overnight 35. Insurance Company Named on Workers Compensation Policy S If yes date 35A. Claim Administrator Name in full Company Name Policy No* Signed by Phone Number Employer or Representative Title Equal Opportunity is the Law Date. Employer s Federal ID Number and Employee Social Security Number MUST be provided* 1. Legal Name E M P L O Y R 2. Business Name 3. Mail Address No* and Street 4. Location if different from Mail Address Zip 5. Telephone Number Extension and Contact Person* 7. Business Name 3. Mail Address No* and Street 4. Location if different from Mail Address Zip 5. Telephone Number Extension and Contact Person* 7. Do you regularly employ 10 or more 8. Federal ID No* employees Yes No Last Name 10. Social Security No* 11. Do you regularly employ 10 or more 8. Federal ID No* employees Yes No Last Name 10. Social Security No* 11. Date of Birth Middle Initial 12. Home Address No* and Street 13. Home Phone No* City State 18. Wages Hours Per Day Per 22. Date of Birth Middle Initial 12. Home Address No* and Street 13. Home Phone No* City State 18. Wages Hours Per Day Per 22. Date of Accident A C I D N T 6. Nature of Business list principal products or service of concern 9. Date of Accident A C I D N T 6. Nature of Business list principal products or service of concern 9. Name First Name Days Per Week Accident Time AM PM 14. Work Phone No 16. Job Title 15. Age 17. Sex F 20. .

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