Free Download VR Cover Page in PDF - Vermont

www.labor.vermont.gov

Department of Labor Workers' Compensation Division PO Box 488 Montpelier, VT 05601-0488 (802) 828-2286

State File No.: Ins. Co. File No.: Date of Injury:

VOCATIONAL REHABILITATION ENTITLEMENT CLOSURE EXTENSION DATE OF REPORT Employee Name Street City/State/Zip DOB Occupation at time of injury Education Treating Physician Represented Yes No ? Employee's E-Mail Address Employer Name Street City/State/Zip Ins. Co. Name Street City/State/Zip Represented ? V R Counselor V R Company Street Address City/State/Zip Phone Rev. 02/07 If yes, attorney name: PLAN SUSPENSION AMENDMENT PROGRESS REPORT

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Telephone No. DOT Code AWW Type of Injury

Telephone No. Referral Date

Telephone No. Adjuster Yes No If yes, attorney name:

Fax