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Workers' Comp Forms

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’ Comp –rev 12-05
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

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]

Form 28 – Notice of Change in Comp Rate for Injuries after 7/1/86 –Rev 5/18

Historical Rates
Fiscal year 2020
Fiscal Year 2019
Fiscal Year 2018
Fiscal Year 2017
Fiscal Year 2016
Fiscal Year 2015
Fiscal Year 2014
Fiscal Year 2013

Form 28a – Notice of Change in Compensation Rate for Injuries before 7/1/86 – Last Revised 6/13

Historical Rates
Fiscal Year 2020
Fiscal Year 2019
Fiscal Year 2018
Fiscal Year 2017
Fiscal Year 2016
Fiscal Year 2015
Fiscal Year 2014
Fiscal Year 2013

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Vermont Department of Labor
5 Green Mountain Drive
P.O. Box 488
Montpelier, 05601-0488
(802) 828-4000

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