Form 1 (Rev. 9/11) 
                                  DEPARTMENT OF LABOR – ATTN:  WORKERS’ COMPENSATION                                        (Approved for use as OSHA 101 and 301) 
                                                               PO Box 488                                                    
                                                 Montpelier, VT 05601-0488                                                    
                                                               (802) 828-2286 
                                                                                                                            State File No.          
                                           EMPLOYER FIRST REPORT OF INJURY                                                   
                                                                                                                              
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:                                                           2. Business                                
E                                                                          Name: 
M 3. Mail Address:  No. and Street                                                                       City                     State            Zip 
P 
                                                                                                                                                           
L 
O 4. Location (if different from Mail Address):                             5. Telephone Number, Extension and Contact Person.: 
Y                                                                                   
E 6. Nature of Business (list principal products or service of      7. Do you regularly employ 10 or more                          8. Federal ID No.: 
R concern):                                                         employees? 
                                                                              Yes                             No                           
  9. Name:  First Name               Middle Initial  Last Name                                                10. Social Security No.:  11. Date of Birth: 
E                                                                                                                                                 
M 12. Home Address:  No. and Street                                 13. Home Phone No.:  14. Work Phone No:  15. Age: 
P 
                                                                                                                                                  
L 
O City                                                      State          Zip         16. Job Title:                                     17. Sex: 
Y                                                                                                                                             M             F
E 18. Wages $           Hours Per Day                       19. If board, lodging, etc. were                          20. Was employee hired in  21. Date of Hire 
E                                                           furnished in addition to wages, state                     VT? 
                                                            estimated value: 
  Per                   Days Per Week                       $                                                               Yes            No            
  22. Date of Accident: Accident Time:                      Began Shift:                                      23. Location of Accident:  Town or  State 
A                                                                                                             City 
C                              AM               PM                 AM              PM                                                                   
C 24. Machine, tool, object, motor vehicle or substance directly causing injury: 
I       
D 
E 25. On employer’s premises?              Yes              No      If yes, name of department:                             
N 26. Describe what employee was doing:                                    Was this the employee’s regular occupation?                            Yes       No
T                                                                           
  27. How did accident occur?  Describe events leading up to the accident: 
        
  28. Describe the injury and the part of the body injured.                                                                 29. Was this a first-aid only injury: 
I                                                                                                                               Yes                        No
N 
J 30. Any Lost Time?    If yes, date disability          Last date paid in  31. Employee returned to                        If yes, date   Medical Only Incident: 
U                       began                            full:              work? 
R    Yes          No                                                                Yes                               No                   Yes       No     
Y 32. Did injury result in death?    If yes, date of death.                                                                    
          Yes           No                                                                                                     
  33. Name and address of Physician:       
  34. Name and address of Hospital:                                                                                   Remained Overnight           Yes            No
  35. Insurance Company Named on Workers’ Compensation Policy                    35A.  Claim Administrator 
I   
N Name in full:                                                                  Company Name                             
S                                                                                                                    
  Policy No.                                                                     Phone Number                             
  Signed by:                                                                                                                       
                Employer or Representative                                             Title                                      Date 
 
                                                            Equal Opportunity is the Law