Vermont.gov
Vermont.gov
   
Employer Portal Claimant Portal
   You Are Here: Forms & PublicationsWC Forms and PublicationsWorkers' Compensation Forms
* Workers' Compensation Forms *
*

The most recent version of the forms are available in Microsoft Word 8.0 format or PDF format.  You may need the free Adobe PDF Reader for some of the forms.  If you don't have Adobe Acrobat Reader, you can download it by clicking here.

Please note:  the Word version of these forms are password protected and do not allow you to save them. 

All of our forms are available in Adobe 9 which will allow you to fill them in and save them.  You do not need Adobe 9 to open and use these forms. 

If you experience any problems with these forms please contact Trudy Smith at trudy.smith@state.vt.us with the specific form number and problem that you are experiencing. 

*
* Form 1 - Employee's Claim & Employer's First Report of Injury - Last Revised 7/08 *
* *
* Form 2 - Denial of Workers' Compensation Benefits - Last Revised 9/09 *
* *
* Form 4 - Report of Fatal Accident - Last Revised 5/05 *
* *
* Form 5 - Employee's Notice of Injury and Claim for Compensation - Last Revised 3/09 *
*
IMPORTANT - Please download and complete this instruction sheet which MUST be included with your Form 5 filing.

Download Form 5 Instruction Sheet in PDF format
*
* Form 6 - Notice and Application for Hearing - Last Revised 9/09 *
* *
* Form 7 - Medical Authorization - Last Revised 11/09 *
* *
* Form 8 - Notice of Intent to Change Health Care Provider - Last Revised 9/09 *
* *
* Form 10/10S - Certificate of Dependency and Employee Exemption Report - Last Revised 9/09 *
* *
* Form 13 - Report of Benefits and Related Expenses Paid - Last Revised 9/09 *
* *
* Form 13A - Aggregate Annual Reporting Form - Reporting Period 7/1 through 6/30 - Last Revised 5/05 *
* *
* Form 14 - Settlement Agreement (medical benefits open) - Last Revised 12/08 *
* *
* Form 15 - Settlement Agreement - Last Revised 12/08 *
* *
* Form 20 - Work Capabilities Form - Last Revised 9/09 *
* *
* Form 21 - Agreement for Temporary Total Disability Compensation - Last Revised 9/09 *
* *
* Form 22 - Agreement for Permanent Partial Disability Compensation - Last Revised 9/09 *
* *
* Form 23 - Agreement for Compensation in Fatal Cases - Last Revised 9/09 *
* *
* Form 24 - Agreement for Temporary Partial Disability Compensation - Last Revised 9/09 *
* *
* Form 25 - Wage Statement - Last Revised 9/09 *
* *
* Form 25M - Memorandum of Payment - Last Revised 8/07 *
* *
* Form 25s - Weekly Net Income Worksheet - Last Revised 9/09 *
* *
* Form 27 - Notice of Intention to Discontinue Payments - Last Revised 9/09 *
* *
* Form 28 - Notice of Change in Compensation Rate for Injuries after 7/1/86 - Last Revised 9/09 *
*
For prior years please contact the Department at (802) 828-2286 or
labor-wccomp@state.vt.us
*
* Form 28a - Notice of Change in Compensation Rate for Injuries before 7/1/86 - Last Revised 9/09 *
* *
* Form 29 - Application for Exclusion from the Provisions of the Workers' Compensation Act - Last Revised 8/09 *
* *
* Form 30 - Application for Self-Insurance - Last Revised 5/05 *
* *
* Form 31 - Notice to Employees: Employer's Liability and Workers' Compensation - Last Revised 12/05 *
* *
* Bond Form for Self-Insured - Last Revised 6/05 *
* *
* Assumption and Guarantee Form *
* *
* Self-Insurer's Report *
* *
* WC Assessment Fund Forms *
*
  • Insurer's Quarterly Assessment Form
  • Insurer's Reconciliation Statement 
    		• *
    * Report of Employer Conducting Business Without Workers' Compensation Insurance - Last Revised 4/08 *
    * *
    * Report of Suspected Workers' Compensation Insurance Fraud - Last Revised 4/08 *
    *
    If you want to submit this form electronically please use the Adobe 9 format, save it and attach it to an e-mail to J. Stephen Monahan at stephen.monahan@state.vt.us.
    		*
    Accessibility Policy Users with Special Needs Privacy Policy Copyright Information Site Map
    Equal Opportunity is the Law. A Vermont Government Website.
    ©2005 State of Vermont. All rights reserved. Admin
    Vermont.govState of Vermont Department of Labor