This Employer, , Has Complied With The Provisions Of Title 21 Of The
Vermont Statutes, Annotated §687, By Obtaining Workers’ Compensation Insurance Coverage Through:


(insurance Carrier)
Workers’ Compensation Benefits For Lost Time, Medical Expenses, Disability Or Because Of A Work-related Injury Are Available Through This Company.
- An Injured Employee Must Immediately Notify His/her Employer Of An Injury.

- The Employer Must File An Employee Claim And Employer’s First Report Of Injury (form 1) With The
Department Of Labor And Industry Within 72 Hours Of The Notice Of An Injury That Requires Medical
Attention Or Results In Time Lost From Work. The Employer Must Also Provide A Copy Of The Form 1 To The Injured Worker And To The Insurance Carrier.

- If The Employer Fails To File A First Report, An Employee May File A Notice Of Injury And Claim For
Compensation (form 5) With The Department Of Labor And Industry Within Six Months Of The Date Of Injury.

- Information Concerning Injured Worker Rights And Benefits Is Available On The Workers’ Compensation
Form 31 2/03