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Employee's Notice of Injury and Claim for Compensation

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EMPLOYEE’S NOTICE OF INJURY AND CLAIM FOR COMPENSATION

State of Vermont

Department of Labor

Workers’ Compensation Division

PO Box 488

Montpelier, VT 05601-0488

DOL FORM 5 (Rev. 9/11)

State File No.

Employee:

Name:

Street:

City:

State: Zip:

DOB:

Social Security No.:

Home Telephone Number:

Work Telephone Number:

Email Address:

Employer:

Legal Name:

D/B/A:

Street:

City:

State: Zip:

Owner/Supervisor Name:

Telephone Number:

Injury:

Date of Injury:

Job Site Location:

Body Part Injured:

Machine or Tool Involved:

Did you notify your employer/supervisor at the time of the injury/illness?

Briefly explain how injury/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 attach all supporting medical documentation.

Employee Signature:

Date Signed:

Attorney Signature (if represented):

Date Signed:

Page 2 of 2 - Instruction Sheet

Employee's Notice of Injury and Claim For Compensation (Form 5)

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 relationship 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 Injury 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 treatment? on what date?

Who chose the first treating medical provider?

Who is currently providing treatment to you?

When is your next appointment date? with whom?

Have you returned to work? - if yes, on what date?

Are you working your regular hours? - 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/illness you should continue to provide updated medical records to the insurance company and this office until a decision is made on your claim.

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What the Employee's Notice of Injury and Claim for Compensation Is

The Employee's Notice of Injury and Claim for Compensation is a formal written report that an employee submits to notify an employer and the relevant workers' compensation authority about a work-related injury or occupational illness. It typically documents the injured worker's name, date and place of injury, a brief description of how the injury occurred, and initial medical treatment. Timely completion preserves benefit rights and triggers employer/insurer obligations. Electronic delivery and signatures are generally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, though some state-specific procedural rules may apply.

Why this Notice Matters for Employees and Employers

Filing the Notice begins the workers' compensation process, creates an official record of notice, and starts timelines for medical care, wage replacement, and insurer investigation. Accurate, prompt reporting reduces disputes over causation and eligibility while preserving statutory rights.

Why this Notice Matters for Employees and Employers

Who completes and receives the form

The form is prepared by the injured employee or an authorized representative and routed to employer, insurer, and the state workers' compensation agency where required.

  • Injured employee — Reports the incident, describes injury, and signs the claim form for record.
  • Human Resources or safety officer — Records the notice, forwards to insurer, and files internal incident report.
  • Claims adjuster or employer representative — Reviews details, arranges medical care, and initiates benefit processing.

Multiple parties keep copies for claims handling, employer records, and possible agency review; follow state-specific routing rules when present.

Primary signers and stakeholders

HR Manager

Human Resources staff typically receive and acknowledge the notice, coordinate with the employer's insurer, ensure OSHA or internal reporting obligations are met, and retain records for compliance and audit purposes.

Injured Employee

The worker filing the notice provides incident details, treatment information, and an attestation of accuracy; accurate identity and dates are essential to preserve claim rights and avoid processing delays.

Required data elements on the form

Employee Name: Full legal name
Date of Injury: MM/DD/YYYY
Location: Street, city, state
Injury Description: Concise factual summary
Medical Treatment: Name of provider
Signature: Typed or signed with date

Consequences of incorrect or late notice

Benefit denial: Late or missing notice can jeopardize benefits
Claim delay: Incomplete details slow investigation
Employer penalties: State sanctions for reporting failures
Fraud exposure: False statements may carry criminal penalties
Medical access impact: Authorized care may be delayed
Recordkeeping risk: Poor retention complicates future disputes

Common preparation mistakes to avoid

  • Providing vague or contradictory injury descriptions that make causation unclear and prompt insurer requests for clarification.
  • Using inconsistent names or dates compared with medical records, which creates administrative mismatch and processing delays.
  • Failing to include initial medical provider details, hindering authorization of treatment and billing clarity.
  • Assuming the employer or insurer will file on your behalf without confirmation, which can lead to missed statutory deadlines.

Step-by-step: completing the Notice and Claim form

Follow these four essential steps to complete the Employee's Notice of Injury and Claim for Compensation accurately and consistently.

  • 01
    Step 1: Enter full legal name and contact details exactly as on ID.
  • 02
    Step 2: Record date, time, and precise location of injury in MM/DD/YYYY.
  • 03
    Step 3: Describe how injury occurred with factual, objective language.
  • 04
    Step 4: Sign and date; retain copies and deliver to employer/insurer.

How to configure an online completion workflow

Set up a simple digital workflow to collect, route, and archive the notice while preserving audit trails and authentication.

Field | Configuration Required | Format and behavior
Employee Contact Required | Email and phone validation
Date Fields Required | MM/DD/YYYY mask
Signature Required | eSignature field with timestamp
Routing Required | Auto-send to HR and insurer

Where the completed notice should go

A completed notice typically routes to several parties to start medical, investigative, and benefit workflows.

  • Employer: Primary recipient for internal incident logging and initial response.
  • Insurer: Claims unit receives the notice to open a claim file and assign an adjuster.
  • State Agency: File with the workers' compensation board where required by jurisdiction.
  • Treating Provider: Share medical details to coordinate care and billing authorization.

Digital submission and platform considerations

Ensure your digital platform supports required file types, secure authentication, and an audit trail for legal compliance.

  • File formats: PDF and DOCX accepted for archival integrity
  • Authentication: Email + optional SMS or KBA for signer identity
  • Integrations: Works with HRIS, case management, and cloud storage

Preserve signed copies, timestamps, and audit logs; platforms that integrate with HR and claims systems reduce manual handoffs and errors.

Typical timelines and filing expectations

Timelines vary by state; act promptly to avoid prejudicing a claim and to secure immediate medical authorization where applicable.

Immediate employer notice:

Report the injury as soon as practicable to preserve rights.

Formal claim filing:

File with agency per state rule; commonly within 30–90 days depending on jurisdiction.

Urgent medical care:

Obtain emergency treatment immediately; notify employer of provider for authorization.

Employer reporting:

Employers must notify insurer and may file first report of injury promptly.

Record retention:

Keep copies until claims resolved and beyond applicable retention period.

Key milestones from injury to claim resolution

A sequential overview highlights the main stages you can expect after an injury is reported.

01

Incident Occurs

Immediate first aid and documentation of circumstances by employee or witness.

02

Employee Notification

Worker reports to employer to create an official notice; employer records the event.

03

Medical Evaluation

Treating provider documents injury and issues work restrictions or referrals.

04

Claim Filing and Adjudication

Insurer investigates, authorizes benefits, and the agency resolves disputes if necessary.

eSignature vendor comparison for filing and signing notices

Compare starting prices and core capabilities relevant to secure signing, bulk sending, audit trails, and HIPAA support; signNow is listed first per vendor comparison convention.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial No No Yes, limited Yes, limited
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Practical tips for accurate, efficient completion

Small steps during completion reduce downstream disputes and speed processing.

Keep entries factual
Avoid opinions or speculation in the injury description; stick to objective facts, dates, witness names, and observable symptoms to reduce insurer follow-up.
Match official records
Use the same name and date formats as medical records and identification documents to avoid verification delays and mismatches in the claims file.
Attach supporting documents
Include initial medical reports, incident photos, and witness statements when available to expedite adjudication and prevent repeated information requests.
Confirm receipt
Obtain written or digital acknowledgement from employer and insurer and preserve audit trails to establish timely notice if disputes arise.

Real-world examples of notice use

Two brief scenarios show how notices operate in practice and the outcomes that accurate filing supports.

Warehouse Strain Incident

An employee reported lifting injury immediately

  • Employer coordinated medical care within 24 hours
  • Complete documentation and timely filing enabled prompt temporary disability benefits while investigation continued.

Construction Fall Report

A subcontractor reported a fall on-site with photos attached

  • Insurer opened claim and authorized X-rays swiftly
  • Clear mechanism of injury and witness statements reduced disputed causation and accelerated benefits.

Frequently asked questions and common issues

Answers to frequent questions help clarify e-signing, deadlines, notarization, and follow-up actions related to the notice and claim form.


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