DOL Form 6 Rev. 9/11 Department of Labor Workers' Compensation Division PO Box 488 Montpelier, VT 05601-0488 (802) 828-2286 State File No. Ins. Co. File No. Date of Injury NOTICE AND APPLICATION FOR HEARING Employee: Name: Street: City State: Home Phone Number: Work Phone Number: Email Address: The accident upon which claim for compensation is based, occurred on the of , 20 in the town of and the state of day Employer: Name: Insurance Carrier: TPA Name: Adjuster Name: Phone Number and Extension Zip: Briefly state the issue(s) in dispute and attach supporting evidence (attach additional pages as necessary and include documentation including medical records): The applicant seeks: Temporary Total Disability Compensation Temporary Partial Disability Compensation Permanent Partial Disability Compensation Permanent Total Disability Compensation Please attach supporting evidence If represented: Attorney Representing Law Firm Employee Employer Medical & Hospital Benefits Vocational Rehabilitation Dependency Benefits (Fatal Claim) Attorney's Fees Please print requesting party name Signature of Requesting Party Date American LegalNet, Inc. www.FormsWorkFlow.com