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Vermont Forms

79 State Forms found

name	number	revision	print or send online
EMPLOYER FIRST REPORT OF INJURY	Form 1	(Rev. 9/11)
EMPLOYEE’S NOTICE OF INJURY AND CLAIM FOR COMPENSATION	DOL Form 5	(Rev. 9/11)
VERMONT WORKERS’ COMPENSATION MEDICAL AUTHORIZATION	Form 7	(Rev. 5/23)
AGGREGATE Annual Reporting Form – Reporting Period 7-01 – 6-30	DOL FORM 13-A	(Rev. 8/16)
AGREEMENT FOR COMPENSATION IN FATAL CASES	DOL Form 23	(Rev. 6/10)
AGREEMENT FOR PERMANENT PARTIAL or PERMANENT TOTAL DISABILITY COMPENSATION	DOL FORM 22	(Rev. 6/10)
AGREEMENT FOR TEMPORARY COMPENSATION	Form 32	(Rev. 6/23)
Application for Self-Insurance	Form No. 30	No Form/Rev Date
Agreement of Assumption and Guarantee of Workers' Compensation Liabilities	No Form Number	No Form/Rev Date
DEPARTMENT OF LABOR - Bond	LI/WC-BOND	(6/05)
Certificate of Dependency and Concurrent Employment	Form 10	(rev 9/11)
Denial of Workers' Compensation Benefits by Employer or Carrier	DOL FORM 2	Rev. 5/2024
MEMORANDUM OF PAYMENT	Form 25M	Rev. 1/15
NOTICE AND APPLICATION FOR HEARING	DOL Form 6	Rev. 9/11
NOTICE OF INTENT TO CHANGE HEALTH CARE PROVIDER	DOL Form 8	Rev. 9/11

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Disclaimer: These forms may not be the most recent version. Vermont may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on this site. Please check official sources.

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