DOL Form 4 Rev 9/11 Department of Labor Workers' Compensation Division PO Box 488 Montpelier, VT 05601-0488 (802) 828-2286 REPORT OF FATAL ACCIDENT State File No. Ins. Co. File No. Date of Injury Soc. Sec. No. IMPORTANT: This report is to be used only when a work related injury results in a fatality. In all such cases, the Employer's First Report of Injury (Form 1) also must be filed. 1. 2. 3. 4. 5. 6. 7. 8. 9. Name of Employer: Address of Employer: Nature of Business: Name of Injured Person: Residence of Injured Person at Time of Death: Date of Accident: Date of Death: Place where Injured Person Died: Single Married Civil Union Widower Widow Divorced 10. Number of Children under Eighteen years of age: 11. If no Spouse or Reciprocal Beneficiary or Children Survive, State Other Relatives Dependent Upon Deceased: 12. Relationship of Dependents: Dated this day of 20 (year) Employer By Official Position American LegalNet, Inc. www.FormsWorkFlow.com