Free State of Vermont - Vermont

VERMONT

State of Vermont Department of Labor Workers' Compensation and Safety Division 5 Green Mountain Drive P.O. Box 488 Montpelier, VT 05601-0488

Report of Employer Conducting Business Without Workers' Compensation Insurance Date of this report Company Name Company Owner(s) Physical Location(s) of Business Mailing Address of Business or Owner Phone Number of Business or Owner Type of Business Number of Employees Evidence of non-compliance with workers' compensation insurance requirements (attach available documentation)

In order for us to follow up with you, please provide the following information. This information is not confidential and may be released under certain circumstances. Name of Complainant Address Phone Number E-mail Address

Relationship to Business or Business Owner: Employee Other Please return the completed form to the mailing address above, or by FAX to (802) 828-2195. Former Employee Competitor Neighbor