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* NEW Weekly Payment Requirements are effective July 1, 2010 *
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Adjusters and Employer/Carriers beware!  


Starting July 1, 2010, you will be required to establish and report to the Department and the claimant in each claim the day of the week on which payment shall be mailed or deposited.  This is true whether benefits have been awarded or are not in dispute, according to the new provisions of 21 V.S.A. sec. 650(f).  We have provided a guidance document for your use. 


Payment Scheduling Clarification Guidance Document


The forms mentioned in this document have been revised and are now available for your use.
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* Workers' Compensation Forms *
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The most recent version of the forms are available in 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.

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. 

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* Form 1 - Employee's Claim & Employer's First Report of Injury - Last Revised 9/11 *
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NOTE: The injured employee must receive a Form 8 and a completed copy of Form 1

 
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* Form 2 - Denial of Workers' Compensation Benefits - Last Revised 9/11 *
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* Form 4 - Report of Fatal Accident - Last Revised 9/11 *
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* Form 5 - Employee's Notice of Injury and Claim for Compensation - Last Revised 9/11 *
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You can also contact Ellen Gonyaw at (802) 828-2286 or ellen.gonyaw@state.vt.us for further information.
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* Form 6 - Notice and Application for Hearing - Last Revised 9/11 *
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* Form 7 - Medical Authorization - Last Revised 1/12 *
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* Form 8 - Notice of Intent to Change Health Care Provider - Last Revised 9/11 *
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* Form 10 - Certificate of Dependency and Concurrent Employment - Last Revised 9/11 *
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* Form 13 - Report of Benefits and Related Expenses Paid - Last Revised 9/09 *
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* Form 13A - Aggregate Annual Reporting Form - Reporting Period 7/1 through 6/30 - Last Revised 5/05 *
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* Form 16 - Settlement Agreement - Last Revised 9/11 *
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* Form 20 - Work Capabilities Form - Last Revised 12/10 *
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* Form 22 - Agreement for Permanent Partial Disability Compensation - Last Revised 6/10 *
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* Form 23 - Agreement for Compensation in Fatal Cases - Last Revised 6/10 *
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* Form 25 - Wage Statement - Last Revised 6/10 *
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* Form 25M - Memorandum of Payment - Last Revised 8/07 *
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* Form 25s - Weekly Net Income Worksheet - Last Revised 9/09 *
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* Form 27 - Notice of Intention to Discontinue Payments - Last Revised 6/10 *
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* Form 28 - Notice of Change in Compensation Rate for Injuries after 7/1/86 - Last Revised 9/09 *
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For prior years please contact the Department at (802) 828-2286 or
labor-wccomp@state.vt.us
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* Form 28a - Notice of Change in Compensation Rate for Injuries before 7/1/86 - Last Revised 9/09 *
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* Form 29 - Application for Exclusion from the Provisions of the Workers' Compensation Act - Last Revised 2/13 *
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* Form 30 - Application for Self-Insurance - Last Revised 5/05 *
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* Form 31 - Notice to Employees: Employer's Liability and Workers' Compensation - Last Revised 12/05 *
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* Form 32 - Agreement for Temporary Compensation - Last Revised 9/11 *
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* Form VR227 - Vocational Rehabilitation Denial/Discontinuance - Last Revised 9/11 *
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* Bond Form for Self-Insured - Last Revised 6/05 *
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* Assumption and Guarantee Form *
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* Self-Insurer's Report *
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* WC Assessment Fund Forms *
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* Report of Employer Conducting Business Without Workers' Compensation Insurance *
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* Report of Suspected Workers' Compensation Insurance Fraud *
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* Medical Provider Preauthorization Form *
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