Workers' Comp Forms
Voc Rehab Forms
- Application for Certification as a Vermont Rehab Professional
- Certified Vocational Rehabilitation Counselors
- Form 25M – Memorandum of Payment [PDF]
- Notice of Intention to Change Vocational Rehabilitation Provider – Updated 8/2013
- Renewal Application for Certification as a VT Rehab Profession
- Voc Rehab Referral Form – Revised 9/2013
- Vocational Rehabilitation Annual Survey [PDF]
- Vocational Rehabilitation Cover Page
- Vocational Rehabilitation Disclosure Statement
- Vocational Rehabilitation Discontinuance Report
- Vocational Rehabilitation Entitlement Assessment [PDF]
- Vocational Rehabilitation Progress Report
- Vocational Rehabilitation Return to Work Plan
- Vocational Rehabilitation Self-Employment Workbook [PDF]
Workers Comp Forms
- Form 1 – Employee’s Claim & Employer’s First Report of Injury – Rev 9/11
- First-Aid Only Injuries and Deductible Policies
- Form 2 – Denial of Workers’ Compensation Benefits – Rev 4-2018
- Form 4 – Report of Fatal Accident – Last Revised 9-11
- Form 5 – Employee’s Notice of Injury and Claim for Compensation –Rev 9-11
- Form 6 – Notice and Application for Hearing – rev 9-11
- Form 7 – Medical Authorization –rev 1-17
- Form 8 – Notice of Intent to Change Health Care Provider –rev 9-11
- Form 10 – Certificate of Dependency and Concurrent Employment –rev 9-11
- Form 13 – Report of Benefits and Related Expenses Paid –rev 9-09
- Form 13A –Aggregate Annual Reporting Form – Report 7-1 thru 6-30 –rev 8-16
- Form 16 – Settlement Agreement –rev 7-14
- Form 20 – Work Capabilities Form –rev 12-10
- Form 22 – Agreement for Permanent Partial Disability Comp –rev 6-10
- Form 23 – Agreement for Comp in Fatal Cases –rev 6-10
- Form 25 – Wage Statement For injuries ON OR AFTER July 1, 2008-rev 1-2018
- Form 25 – Wage Statement For injuries BEFORE July 1, 2008- rev 9-13
- Form 25M – Memorandum of Payment –rev 1-15
- Form 25s – Weekly Net Income Worksheet –rev 9-09
- Form 27 – Notice of Intention to Discontinue Payments –rev 5-18
- Form 29 – Application for Exclusion from Provisions of the Workers’ Comp Act –rev 2-13
- Form 30 – Application for Self-Insurance –rev 4-16
- Form 31 – Notice to Employees: Employer’s Liability and Workers’ Compensation - English
- Form 31 Spanish
- Form 31 Vietnamese
- Form 31 French
- Form 31 Serbo Croatian
- Form 32 – Agreement for Temporary Compensation –rev 12-17
- Form VR227 – Voc Rehab Denial Discontinuance –rev 9-11
- Assumption and Guarantee Form
- Bond Form for Self-Insured – Last Revised 6/05
- Health Care Provider Report
- Workers’ Compensation Alternative Dispute Resolution Report
