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Vermont Form Center -

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Form

Description

Form01.pdf Employees Claim and Employer First Report of Injury
Form02.pdf Denial of Workers Compensation Benefits
Form04.pdf Report of Fatal Accident
05.pdf Employees Notice of Injury and Claim for Compensation
Form06.pdf Notice and Application for Hearing
Form07.pdf Medical Authorization
Form08.pdf Notice of Intent to Change Health Care Provider
10.pdf Certificate of Dependency and Concurrent Employment
13.pdf Report of Benefits and Related Expenses Paid
13a.pdf Aggregate Annual Reporting Form -- Reporting Period 7/01 -- 6/30
16.pdf Settlement Agreement
20.pdf Work Capabilities Form
22.pdf Agreement for Permanent Partial Disability Compensation
23.pdf Agreement for Compensation in Fatal Cases
25.pdf Wage Statement (for dates of accident prior to July 1, 2008)
Form25_070108.pdf Wage Statement (for dates of accident on or after July 1, 2008)
25s.pdf Weekly Net Income Worksheet
27.pdf Employer's Notice of Intention to Discontinue Payments
28fy17.pdf Notice of Change in Compensation Rate (for Injuries after July 1, 1986)
28afy17.pdf Notice of Change in Compensation Rate (for Injuries before July 1, 1986)
28fy16.pdf Notice of Change in Compensation Rate (for Injuries after July 1, 1986)
28afy16.pdf Notice of Change in Compensation Rate (for Injuries before July 1, 1986)
28fy15.pdf Notice of Change in Compensation Rate (for Injuries after July 1, 1986)
28afy15.pdf Notice of Change in Compensation Rate (for Injuries before July 1, 1986)
28fy14.pdf Notice of Change in Compensation Rate (for Injuries after July 1, 1986)
28afy14.pdf Notice of Change in Compensation Rate (for Injuries before July 1, 1986)
28fy13.pdf Notice of Change in Compensation Rate (for Injuries after July 1, 1986)
28afy13.pdf Notice of Change in Compensation Rate (for Injuries before July 1, 1986)
28fy12.pdf Notice of Change in Compensation Rate (for Injuries after July 1, 1986)
28afy12.pdf Notice of Change in Compensation Rate (for Injuries before July 1, 1986)
29.pdf Application for Exclusion from the Provisions of the Vermont Workers Compensation Act
30.pdf Application for Self Insurance
32.pdf Agreement for Temporary Compensation
vr227.pdf Vocational Rehabilitation Denial / Discontinuance
SIbond.pdf Bond Form for Self-Insured
AssumptionandGuarantee.pdf Assumption and Guarantee Form
selfinsured.pdf Self-Insured Report
assessment.pdf Workers' Compensation Administration Fund Quarterly Assessment Statement
wcinstructions.pdf Quarterly Assessment Statement Submission Instructions
reconstmt.pdf Insurer's Reconciliation Statement
noinsurance.pdf Report of Employer Conducting Business Without Workers Compensation Insurance - Last Revised
fraud.pdf Report of Suspected Workers Compensation Insurance Fraud
preauth.pdf Medical Provider Preauthorization Request
healthreport.pdf HCP1 Health Care Provider Report
disputeresolution.pdf Workers' Compensation Alternative Dispute Resolution Report
25m.pdf Memorandum of Payment
VRannualreport.pdf Vocational Rehabilitation Annual Survey Form
VRForm1.pdf Vocational Rehabilitation Referral Form
VRcoverpage.pdf Cover Page
VRdiscontinuance.pdf Vocational Rehabilitation Discontinuance Report
VRentitlementassess.pdf Entitlement Assessment
Return_To_Work_Plan.pdf Return to Work Plan
VRprogressrpt.pdf Vocational Rehabilitation Progress Report
VRdisclosure.pdf Vocational Rehabilitation Disclosure Statement
VRchangeprov.pdf Notice of Intent to Change Vocational Rehabilitation Provider
VRSelfemploymtwkbk.pdf Self-Employment Workbook
VRApplication.pdf Application for Vermont Certification as a Vocational Rehabilitation Counselor or Intern
VRrenewalapp.pdf Renewal Application for Vermont Certification Vocational Rehabilitation Counselor or Job Developer/Intern
VRScreening.pdf Vocational Rehabilitation Screening Notice and Response Form
Noticetoemployeesenglish.pdf POSTER -Employers Liability and Workers Compensation Poster (Form 31)
Noticetoemployeesspanish.pdf POSTER -Employers Liability and Workers Compensation Poster (Spanish) (Form 31)
WC-9.pdf POSTER- WC-9 Employers Reinstatement Liability Poster
wcbrochure.pdf BROCHURE - Rights and Benefits for Workers Injured on the Job
jobsearch.pdf Job Search Tool
milereimb.pdf Mileage Reimbursement Tool