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Report a claim for VERMONT

EMPLOYER'S FIRST REPORT OF INJURY

Fields marked with an asterisk (*) are required—you cannot submit the form unless these fields are completed.

 
10. Do you regularly employ 10 or more employees?
24. Sex*
25. Marital status*

30. Was employee hired in VT
33. Date of Accident*
34. Accident time
35. Began shift
39. On employer's premises?
42. Was this the employee's regular occupation?
47. Was this a first-aid only injury*
48. Any lost time*
51. Employee returned to work?*
53. Medical only incident:
54. Did injury result in death?
55. If yes, date of death
58. Remained overnight
65. Attachment field (medical records)
( 9.5mb limit for all files )
X

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