Form 1 - Employee'S Claim And Employer First Report Of Injury - 2000

STATE OF VERMONT

Form 1

(Rev. 12/00)

(Approved for use as OSHA 101)

DEPARTMENT OF LABOR AND INDUSTRY

Drawer 20

State File No.

Montpelier, VT 05620-3401

EMPLOYEE’ S CLAIM AND EMPLOYER FIRST REPORT OF INJURY

Complete form in ink or typewriter and send original to the Commissioner of Labor and Industry within 72 hours of accident. Send duplicate to your workers’ compensation insurance

company, give Employee’ s copy to employee and retain Employer’ s copy for your files. Answer every question fully and report promptly to avoid a penalty. Employer’ s Federal ID Number

and Employee’ s Social Security Number MUST be provided.

E

1,Legal Name:

2.Business Name:

M

P

3. Mail Address:

No. and Street

City

State

Zip

L

4. Location (if different from Mail Address):

O

Federal ID No.

Y

E

5. Nature of Business (list principal products or service of concern):

Do you regularly employ 10 or more

Telephone No.

employees?

R

Yes

No

9. Date of birth:

E

6. Name:

First Name

Middle Initial

Last Name

8. Social Security No.

M

P

7. Home Address:

No. and Street

Telephone No.

10. Job Title:

9A. Age

L

O

City or Town

State

Zip

12. Dept. assigned to:

11. Sex

M

F

Y

E

13. Wages $

Hours Per Day

14. If board, lodging, etc. were furnished in addition to

15. Was employee hired in

16. Date of Hire

wages, state estimated value:

VT?

Per

Days Per Week

E

$

No

Yes

A

17. Date of Accident:

Hour

20.Machine or tool involved in the accident:

a.m.

p.m.

C

18. Location of Accident:

Town or City

State

21. Was it defective?

No

Yes

If yes, describe how.

C

19.On employer’ s premises?

No

Yes

22.Object or substance directly causing injury:

If yes, name of dept.:

I

23. Describe what employee was doing:

Was this the employee’ s regular

occupation?

No

Yes

D

24.How did accident occur? Describe events leading up to the accident.

E

25.Can the employer prevent this type of accident?

No

Yes

If yes, describe how.

N

26. Was safety equipment, such as goggles or guards, etc. provided?

No

Yes

T

27. Could the injured have prevented this type of accident?

No

Yes

If yes, describe how (do not say, “ By being more careful.” ).

28. If safety equipment was provided, was it being used?

No

Yes

I

29. Describe the injury and the part of body injured.

N

J

30. Any Lost Time?

If yes, date disability began.

Last date paid in full:

31. Employee returned to work?

If yes, date returned.

At what weekly wage:

No

Yes

No

Yes

$

U

R

32.Did injury result in death?

If yes, date of death.

33. If death, name and address of nearest relative.

Relationship

Y

No

Yes

34. Name and Address of Physician

35. Name and Address of Hospital

I

36.Workers’ Compensation Insurance Carrier. Do NOT give your insurance agent’ s name.

N

S

Name in full:

Policy No.

Signed by:

Employer or Representative

Title

Date

____Provided Form 8

____ Labor & Industry

____ Ins. Co.

____Employer

____Employee