Fill and Sign the Employees Notice of Injury and Claim for Compensation Form

DOL FORM 5 (Rev. 9/11) State of Vermont Department of Labor State File No. Workers’ Compensation Division PO Box 488 Montpelier, VT 05601-0488 EMPLOYEE’S NOTICE OF INJURY AND CLAIM FOR COMPENSATION Employee: Employer: Name: Legal Name: Street: D/B/A: City: Street: State: Zip: City: DOB: State: Zip: Social Security No.: Owner/Supervisor Name: Home Telephone Number: Telephone Number: Work Telephone Number: Email Address: Injury: Date of Injury: Body Part Injured: Job Site Location: Machine or Tool Involved: Did you notify your employer/supervisor at the time of the injury/illness? No Yes – Date: Briefly explain how in jury/illness occurred: EMPLOYEE SEEKS COMPENSATION FOR: Lost Time Benefits: Medical Benefits: Both: If you lost time from work, indicate period of lost time From: To: Dependency Benefits: Name of Dependent Date of Birth Relationship In all cases to facilitate the processing of this claim please atta ch all supporting medical documentation. Employee Signature Date Signed Attorney Signature (if repres ented) Date Signed Page 1 of 2 Page 2 of 2 Employee's Notice of Injury and Claim For Compensation (Form 5) INSTRUCTION SHEET In workers' compensation claims the injured worker has the burden of proving that his or her injuries are work related. The injured worker must demonstrate through medical evidence the extent of the injuries and disability as well as the causal relatio nship to the work injury. In order to process your claim for workers' compensation benefits you MUST provide the following information: 1. Complete the attached Employee's Notice of Inju ry and Claim For Compensation (Form 5). If you are claiming lost time from work, please also complete the attached Certificate of Dependency and Employee Exemption Report (Form 10/10s). 2. Enclose copies of relevant medical records. This is required to process your claim. Check off and attach any of the relevant medical records noted below: ___ treatment notes from each office visit you had with any medical provider ___ emergency room records ___ radiology reports (not films) ___ chiropractic records ___ physical therapy notes ___ written clarification from your treating providers as to whether they feel your condition is work- related (strongly recommended). 3. List names of any witnesses to your injury or persons involved in your accident. If possible, include contact information and attach written statement which are signed and dated. __________________________________ 4. Answer the following questions (attach additional sheets if necessary) What are your present symptoms? ___________________________________ Where did you first receive tr eatment? ________________on what date?_ _____ Who chose the first treating medi cal provider? ____ you ___ employer Who is currently providing treatment to you? _____________________ When is your next appointment date? _______ with whom?_______________ Have you returned to work? ___yes ___ no - if yes, on what date? _______ Are you working your regular hours? ___yes ___no - if no, hours working _____ Return this instruction sheet with the Form 5 and Form 10 to the Dept. address above. It is recommended that you keep copies of all submitted information for your records. If you are still receiving treatment for your injury/il lness you should continue to provide upda ted medical records to the insurance company and this office until a d ecision is made on your claim.