![]() Enlarge image | 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 |