Free Department of Labor - Vermont


File Size: 36.2 kB
Pages: 1
Date: April 21, 2009
File Format: PDF
State: Vermont
Category: Workers Compensation
Author: Trudy Smith
Word Count: 86 Words, 552 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.labor.vermont.gov/Portals/0/WC/liselfassessFillIn.pdf

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Department of Labor 5 Green Mountain Drive, PO Box 488 Montpelier, VT 05601-0488

SELF-INSURER'S REPORT
DUE MARCH 1st Calendar Year: Company: 1. Total Workers' Compensation Benefits paid for the reporting period: (a) (b) (c) (d) 2. Assessment due [line (d) x .01]: Indemnity: Medical: Other: Total: $ $ $ $ $

3. Claims for which benefits were paid for this reporting period. (this may be included on a separate form provided that all the information requested is present): Name Date of Injury State File Number

LI SELF ASSESS (2/96) ­ REVISED 3/07