Loading
Form preview picture

Get VT Form 1 2011-2024

DEPARTMENT OF LABOR ATTN WORKERS COMPENSATION PO Box 488 Montpelier VT 05601-0488 802 828-2286 Form 1 Rev. 9/11 Approved for use as OSHA 101 and 301 State File No. EMPLOYER FIRST REPORT OF INJURY 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 R 2. Business Name 3. Mail Address No* and Street 4. Location if different from Mail Address Zip 5. Telephone Number Extension and Contact Person* 7. Do you regularly employ 10 or more 8. Federal ID No* employees Yes No Last Name 10. Social Security No* 11. Date of Birth Middle Initial 12. Home Address No* and Street 13. Home Phone No* City State 18. Wages Hours Per Day Per 22. Date of Accident A C I D N T 6. Nature of Business list principal products or service of concern 9. Name First Name Days Per Week Accident Time AM PM 14. Work Phone No 16. Job Title 15. Age 17. Sex F 20. Was employee hired in 21. Date of Hire VT 19. If board lodging etc* were furnished in addition to wages state estimated value Began Shift 23. Location of Accident Town or 24. Machine tool object motor vehicle or substance directly causing injury 25. On employer s premises 26. Describe what employee was doing If yes name of department Was this the employee s regular occupation 27. How did accident occur Describe events leading up to the accident 28. Describe the injury and the part of the body injured* J U 30. Any Lost Time If yes date disability began 29. Was this a first-aid only injury Last date paid in full 32. Did injury result in death 33. Name and address of Physician 31. Employee returned to work Medical Only Incident If yes date of death. Remained Overnight 35. Insurance Company Named on Workers Compensation Policy S If yes date 35A. Claim Administrator Name in full Company Name Policy No* Signed by Phone Number Employer or Representative Title Equal Opportunity is the Law Date. Employer s Federal ID Number and Employee Social Security Number MUST be provided* 1. Legal Name E M P L O Y R 2. Business Name 3. Mail Address No* and Street 4. Location if different from Mail Address Zip 5. Telephone Number Extension and Contact Person* 7. Business Name 3. Mail Address No* and Street 4. Location if different from Mail Address Zip 5. Telephone Number Extension and Contact Person* 7. Do you regularly employ 10 or more 8. Federal ID No* employees Yes No Last Name 10. Social Security No* 11. Do you regularly employ 10 or more 8. Federal ID No* employees Yes No Last Name 10. Social Security No* 11. Date of Birth Middle Initial 12. Home Address No* and Street 13. Home Phone No* City State 18. Wages Hours Per Day Per 22. Date of Birth Middle Initial 12. Home Address No* and Street 13. Home Phone No* City State 18. Wages Hours Per Day Per 22. Date of Accident A C I D N T 6. Nature of Business list principal products or service of concern 9. Date of Accident A C I D N T 6. Nature of Business list principal products or service of concern 9. Name First Name Days Per Week Accident Time AM PM 14. Work Phone No 16. Job Title 15. Age 17. Sex F 20. .

How It Works

vermont employer 1st rating
4.88Satisfied
34 votes

Tips on how to fill out, edit and sign Vermont form 1 online

How to fill out and sign Vt first injury online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Experience all the key benefits of submitting and completing legal documents on the internet. With our service completing VT Form 1 usually takes a matter of minutes. We make that achievable by offering you access to our full-fledged editor capable of changing/fixing a document?s original textual content, inserting unique fields, and putting your signature on.

Execute VT Form 1 in just a few moments following the instructions listed below:

  1. Pick the document template you will need in the library of legal forms.
  2. Click the Get form key to open the document and start editing.
  3. Submit all of the required boxes (they are marked in yellow).
  4. The Signature Wizard will help you put your electronic signature right after you have finished imputing details.
  5. Put the date.
  6. Look through the entire form to ensure you?ve filled out everything and no corrections are needed.
  7. Press Done and download the resulting template to the computer.

Send your VT Form 1 in a digital form right after you finish completing it. Your information is securely protected, as we keep to the newest security criteria. Join numerous satisfied customers that are already submitting legal documents straight from their houses.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Video instructions and help with filling out and completing vt first report injury

Go paperless, fill in and modify your Form on the web using expert-made templates. This video guide will provide you with all the information and know-how you need to start now.

Vermont first injury FAQ

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to vt first report of injury

  • vermont employer first
  • vermont first report
  • vt first report
  • vt form injury
  • vermont form injury
  • vermont first report injury
  • vt 1st injury
  • vt 1st report
  • vt employer 1st
  • vt employer first
  • vermont form first
  • vermont form 1st
  • vt form 1st
  • vermont 1st injury
  • furnished
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.