Employer First Report Of Injury {1}

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