DEPARTMENT OF LABOR – ATTN: WORKERS’ COMPENSATION PO Box 488 Montpelier, VT 05601-0488 Form 1 (Rev. 2/09) (Approved for use as OSHA 101 and 301) State File No. EMPLOYER FIRST REPORT OF INJURY Complete form and send original to the Commissioner of Labor within 72 hours of accident. Send duplicate to your workers’ compensation insurance company, give Employee’s copy to employee and retain Employer’s copy for your files. 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 E R 2. Business Name: 3. Mail Address: No. and Street City 4. Location (if different from Mail Address): 6. Nature of Business (list principal products or service of concern): A C C I D E N T Middle Initial 7. Do you regularly employ 10 or more employees? Yes No 10. Social Security No.: 11. Date of Birth: 13. Telephone No.: City 14. Job Title: 15. Age: State Hours Per Day Per 22. Date of Accident: 8. Telephone No.: Last Name 12. Home Address: No. and Street 18. Wages $ Zip 5. Federal ID No.: 9. Name: First Name E M P L O Y E E State Days Per Week Accident Time: AM PM Zip 16. Dept. assigned to: 17. Sex: M F 19. If board, lodging, etc. were furnished in 20. Was employee hired in 21. Date of Hire addition to wages, state estimated value: VT? Yes No $ Began Shift: 23. Location of Accident: Town or City State AM PM 24. Machine or tool involved in the accident: 26. On employer’s premises? If yes, name of department: 25. Was it defective? Yes No Yes No 27. Object or substance directly causing injury: 28. Describe what employee was doing: Was this the employee’s regular occupation? Yes No 29. How did accident occur? Describe events leading up to the accident: 30. Can the employer prevent this type of accident? Yes No Yes 31. Was safety equipment, such as goggles or guards, etc. provided? If yes, describe how. No 32. Could the injured have prevented this type of accident? Yes No 33. If safety equipment was provided, was it being used? Yes No 34. Describe the injury and the part of the body injured. I N J U R Y 36. Any Lost Time? Yes If yes, date disability began If yes, describe how (do not say “By being more careful”. 35. Was this a first-aid only injury: Last date paid in full: 37. Employee returned to work? No Yes 38. Did injury result in death? Yes No If yes, date of death. Yes If yes, date No At what weekly wage: No 39. If death, name and address of nearest relative. Relationship 40. Name and address of Physician 41. Name and address of Hospital: Yes Remained Overnight No 42. Workers’ Compensation Insurance Carrier. Do NOT give your insurance agent’s name. I N S Name in full: Policy No. Signed by: Employer or Representative ___Provided Form 8 Title ___Dept. of Labor ___Ins. Co. ___ Employer Date ___Employee Equal Opportunity is the Law American LegalNet, Inc. www.FormsWorkFlow.com