Free DOL FORM 5 (Rev - Vermont

DOL FORM 5 (Rev. 3/09)

State of Vermont Department of Labor Workers' Compensation Division PO Box 488 Montpelier, VT 05601-0488

State File No.

EMPLOYEE'S NOTICE OF INJURY AND CLAIM FOR COMPENSATION
Employee: Name: Street: City: State: DOB: Social Security No.: Telephone Number: Injury: Date of Injury: Body Part Injured: Job Site Location: Machine or Tool Involved: Did you notify your employer/supervisor at the time of the injury/illness? Yes Briefly explain how injury/illness occurred: Employer: Legal Name: D/B/A: Street: City: State: Owner/Supervisor Name: Telephone Number:

Zip:

Zip:

No

EMPLOYEE SEEKS COMPENSATION FOR: Lost Time Benefits: Medical Benefits: If claimant lost time benefits, indicate period of lost time

Both: From: To:

In either case, if claimant lost time or medical benefits, medical documentation MUST be attached.

Employee Signature

Attorney Signature

*** TO BE COMPLETED BY THE DEPARTMENT OF LABOR***
Workers' Compensation Insurance Carrier: Policy Period: Policy Number: To: Policy Cancelled: