Free DOL Form 13 (Rev - Vermont

DOL FORM 13-A (Rev. 5/05) Reporter's Fed. Id No. Fiscal Year

Department of Labor Workers' Compensation Division PO Box 488 Montpelier, VT 05601-0488 www.labor.vermont.gov AGGREGATE Annual Reporting Form ­ Reporting Period 7/01 ­ 6/30
Carrier: NAIC#_ ________________________________________ for Carrier:_ __________________________________________________

Third Party Administrator: Self-Insured:

NAME: ADDRESS: CONTACT PERSON: CONTACT PHONE NUMBER:
Benefit or Expense Paid Out

E-MAIL:
Total # Claims in which Benefit/Expense was Paid Total Amount Paid (all claims) Average benefit/cost per claim

1 2 3 4 5 6 7 8 9 10 11

Temporary Total Disability - Form 21 Temporary Partial Disability ­ Form 24 Permanent Partial Impairment ­ Form 22 Permanent Total Impairment ­ Form 22 Medical Vocational Rehabilitation Fatality (Spouse/dependent) ­ Form 23 Funeral Lump Sum Payments (Form 22, 14 or 15)* Legal Expenses (Defense) TOTAL All Benefits/Expenses Paid

$ $ $ $ $ $ $ $ $ $ $
Total Number

$ $ $ $ $ $ $ $ $ $ $

12 13 14 15

First Reports of Injury, Form 1 Fatalities Medical Only Claims

Attach a list of all employers this report reflects.

INSTRUCTIONS: 1. 2. 3. 4. COMPLETE each blank. Use N/A if appropriate. Provide information for FISCAL YEAR (7/1 ­ 6/30) ONLY. Do NOT duplicate report. If TPA is used, employer/carrier/TPA should agree upon annual reporter. *Attach itemization of lump sums of Form 14, 15 and 22 if known.