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At Workers' Compensation Shop.com we offer free access to Vermont's workers' compensation forms, applications and guides. We strive to keep our library as up to date as possible.
As with all information we provide, please verify the accuracy of this information with the Vermont Division of Workers' Compensation and Safety.
If you have questions about a workers' comp form feel free to contact a specialist at 888-611-7467. We want to be your source for workers' compensation information, rates and quotes in Vermont.
VT Acord 130 Workers' Compensation Application.
The standard Acord 130 application form for workers' comp coverage in Vermont.
Vermont First Report of Injury Form.
RI First Report of Injury Form. Employers should complete this form and send to their insurance company each time an injury occurs.
Vermont Application for Exclusion of Officers and Stockholders
Owners and Officers of corporations should complete this form to exclude themselves from a workers' compensation policy.
Vermont Application for Certificate of Dependency and Employee Exemption Report
This form must be completed by injured workers to determine the employee right to additional compensation for dependents.
Vermont Application for Self Insurance
Complete this form to apply for the right to self insure you company.
Vermont Application for Denial of Benefits
Employers must file this application to appeal for a denial of workers' compensation benefits.
Vermont Employee Instruction Sheet
This step by step instruction sheet provides the injured worker with a checklist of items that need to be prepared when filing a workers' compensation claim.
Employee Notice of Injury Form
Complete this form to notify the employer on your work related injury.
Notice to Employees
This form is to be displayed by the employer to display workers' compensation information to the employees.
Each state has its own laws and requirements regarding when and how employers are allowed to opt-out of coverage under their workers' compensation policy. Some states make it easier than others because they don't require anything to be filed. Other states require special inclusion or exclusion affidavit documentation. Failure to comply often causes employers to have to pay premium on themselves even when they wanted to be excluded form coverage.
A waiver of subrogation means that a business and their insurance company is foregoing all rights to file suit, or seek damages, from another business. This is common in the construction industry as builders attempt to protect their company from negligence. A workers' comp waiver of subrogation does not prevent an injured employee from filing a lawsuit for damages. This coverage typically add about $100 to the cost of a work comp policy.
A Certificate of Insurance is a document that serves as evidence of insurance or proof of coverage. Certificates indicate your current coverages and policy limits. Insurance Agencies issue on an insured's behalf and they often list a third party as a certificate holder. This means they should be notified if a policy cancels prior to expiration. Requests for any special wording should be carefully checked against the policy language before being added to a certificate as they can create legal issues with coverage.
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State Resources for Vermont
Vermont Department Of Labor
Division of Workers' Compensation and SafetyNational Life Building, Drawer 20Montpelier, Vermont 05620-3401802-828-2286 labor.vermont.gov/
National Council on Compensation Insurance (NCCI)
901 Peninsula Corporate CircleBoca Raton, FL 33487-1362800-622-4123 www.ncci.com/
Workers' compensation insurance is required by law for Vermont employers.
Vermont forms and applications such as owners inclusion or exclusion forms are sometimes updated by the state. Contact us if you need help or can't find the workers' compensation form your need for Vermont.
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