DOL FORM 5 (Rev. 9/11) 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: Zip: DOB: Social Security No.: Home Telephone Number: Work Telephone Number: Email Address: 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? No Yes ­ Date: Briefly explain how injury/illness occurred: Employer: Legal Name: D/B/A: Street: City: State: Owner/Supervisor Name: Telephone Number: Zip: EMPLOYEE SEEKS COMPENSATION FOR: Lost Time Benefits: Medical Benefits: If you lost time from work, indicate period of lost time Dependency Benefits: Name of Dependent Date of Birth Both: From: To: Relationship In all cases to facilitate the processing of this claim please attach all supporting medical documentation. Employee Signature Date Signed Attorney Signature (if represented) Date Signed Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Employee's Notice of Injury and Claim For Compensation (Form 5) INSTRUCTION SHEET In workers' compensation claims the injured worker has the burden of proving that his or her injuries are work related. The injured worker must demonstrate through medical evidence the extent of the injuries and disability as well as the causal relationship to the work injury. In order to process your claim for workers' compensation benefits you MUST provide the following information: 1. Complete the attached Employee's Notice of Injury and Claim For Compensation (Form 5). If you are claiming lost time from work, please also complete the attached Certificate of Dependency and Employee Exemption Report (Form 10/10s). 2. Enclose copies of relevant medical records. This is required to process your claim. Check off and attach any of the relevant medical records noted below: ___ treatment notes from each office visit you had with any medical provider ___ emergency room records ___ radiology reports (not films) ___ chiropractic records ___ physical therapy notes ___ written clarification from your treating providers as to whether they feel your condition is workrelated (strongly recommended). 3. List names of any witnesses to your injury or persons involved in your accident. If possible, include contact information and attach written statement which are signed and dated. __________________________________ 4. Answer the following questions (attach additional sheets if necessary) What are your present symptoms? ___________________________________ Where did you first receive treatment? ________________on what date?______ Who chose the first treating medical provider? ____ you ___ employer Who is currently providing treatment to you? _____________________ When is your next appointment date? _______ with whom?_______________ Have you returned to work? ___yes ___ no - if yes, on what date? _______ Are you working your regular hours? ___yes ___no - if no, hours working _____ Return this instruction sheet with the Form 5 and Form 10 to the Dept. address above. It is recommended that you keep copies of all submitted information for your records. If you are still receiving treatment for your injury/illness you should continue to provide updated medical records to the insurance company and this office until a decision is made on your claim. American LegalNet, Inc. www.FormsWorkFlow.com