Free Download Form 1 in Adobe 9 Fill In Format - Vermont

DEPARTMENT OF LABOR ­ ATTN: WORKERS' COMPENSATION PO Box 488 Montpelier, VT 05601-0488 EMPLOYER FIRST REPORT OF INJURY

Form 1 (Rev. 2/09) (Approved for use as OSHA 101 and 301)

State File No. 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 Social Security Number MUST be provided. 1. Legal Name: E M P L O Y E R E M P L O Y E E A C C I D E N T 3. Mail Address: No. and Street 4. Location (if different from Mail Address): 6. Nature of Business (list principal products or service of concern): 9. Name: First Name 12. Home Address: No. and Street City 18. Wages $ Per 22. Date of Accident: Hours Per Day Days Per Week Accident Time: AM State Middle Initial 2. Business Name: City 5. Federal ID No.: 7. Do you regularly employ 10 or more employees? Yes No Last Name 13. Telephone No.: Zip 10. Social Security No.: 14. Job Title: 16. Dept. assigned to: 8. Telephone No.: 11. Date of Birth: 15. Age: State Zip

PM

17. Sex: M F 19. If board, lodging, etc. were furnished in 20. Was employee hired in 21. Date of Hire addition to wages, state estimated value: VT? $ Yes No Began Shift: 23. Location of Accident: Town or City State AM PM 25. Was it defective? Yes No

24. Machine or tool involved in the accident: 26. On employer's premises? If yes, name of department: 28. Describe what employee was doing: 29. How did accident occur? Describe events leading up to the accident: 30. Can the employer prevent this type of accident? 31. Was safety equipment, such as goggles or guards, etc. provided? 32. Could the injured have prevented this type of accident? 33. If safety equipment was provided, was it being used? 34. Describe the injury and the part of the body injured. Yes Yes Yes No Yes No No Yes No

27. Object or substance directly causing injury: Was this the employee's regular occupation? Yes No

If yes, describe how. No If yes, describe how (do not say "By being more careful".

I N J U R Y

35. Was this a first-aid only injury:
Last date paid in full: 37. Employee returned to work? Yes No Relationship If yes, date

Yes

No

36. Any Lost Time? Yes No

If yes, date disability began

At what weekly wage:

38. Did injury result in death? Yes No 41. Name and address of Hospital:

If yes, date of death.

39. If death, name and address of nearest relative.

40. Name and address of Physician Remained Overnight Yes No

42. Workers' Compensation Insurance Carrier. Do NOT give your insurance agent's name. I N S Name in full: Signed by: Employer or Representative ___Provided Form 8 ___Dept. of Labor ___Ins. Co. Title ___ Employer ___Employee Date Policy No.

Equal Opportunity is the Law