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Vermont Department of Labor Form 25

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WAGE STATEMENT – For injuries occurring on or after July 1, 2008

Department of Labor, Workers’ Compensation

PO Box 488

Montpelier, VT 05601-0488

(802) 828-2286; TDD 800-650-4152

www.labor.vermont.gov

DOL FORM 25 (Rev. 1/2018)

State File No.

Ins. Co. File No.

Date of Injury

Fed. ID No.

Employee:

Employer:

Wage Rate: $ per
Number of Days Hired to Work:
Number of Hours Hired to Work:
# Week Ending Number of Hours or Days Worked Gross Wages Extras (as in 6 or 7)
Please indicate what the extra is, for example, $1000.00 bonus
  Month Day Year      
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

INSTRUCTIONS:
Read Carefully

1. Enter GROSS wages of employee for 26 weeks before date of accident (NOT take-home pay).

2. Do not include the week of the accident.

3. Leave blank those weeks in which the employee had excused absences for which he/she was paid for less than ½ of a work week.

4. Leave blank those weeks in which you had reduced operations or a plant shutdown and for which the employee was paid for less than ½ of a work week.

5. Do not enter those weeks in which an employee was on vacation for more than ½ of a work week.

6. If room, board, lodging or other “extras” are provided in addition to monetary wages, break these down into a weekly value, and include and describe the income in the column marked “EXTRAS.” This includes tips if not included in gross wages.

7. Include any bonuses and commissions paid to the employee in addition to wages in the column marked “EXTRAS.”

8. Enter the dates when your normal work week ends (not the date a check is issued to the employee) and the number of hours or days worked.

When did the employee begin losing time?

Was the employee paid in full for the day of the accident? Yes No

Are employee’s wages subject to any child support withholding order? Yes No

If yes, in what amount? $ per

Day of the week the check will be mailed to the claimant or deposited in the claimant’s account

This is a correct statement of the employee’s earnings as taken from the employer’s payroll records.

By:

Signature of Preparer

Position Title:

Print Name:

Date:

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What the Vermont Department of Labor Form 25 Is

The Vermont Department of Labor Form 25 is a state administrative form used in employer–labor reporting and related workforce compliance processes. The form collects employer, payroll, and event-specific details so the Department can process claims, contributions, or status changes. This guide explains who uses Form 25, which fields are required, how to complete each section accurately, options for electronic submission, and practical recordkeeping and retention considerations for employers and payroll administrators.

Why completing Form 25 carefully matters

Accurate completion reduces delays, prevents penalties, and preserves employer rights during audits or benefit disputes. Correct data supports timely processing by the Department and helps avoid downstream tax and unemployment reporting errors.

Why completing Form 25 carefully matters

Who typically completes Vermont Department of Labor Form 25

Employers, payroll teams, HR professionals, and third‑party payroll vendors usually prepare Form 25 when reporting employer-specific events to the Vermont Department of Labor.

  • Small business owners who handle payroll and benefits reporting themselves for a single or few employees.
  • Payroll service providers and PEOs reporting on behalf of multiple client employers.
  • Human resources staff at mid‑sized and large employers managing contribution and claim correspondence.

Ensure the person completing the form has access to payroll records, employer account numbers, and any supporting documentation needed to substantiate entries.

Stepwise completion process for Vermont Department of Labor Form 25

Follow these steps in order to gather records, populate fields, validate entries, and submit the form to avoid common processing delays.

  • 01
    Gather records: Collect payroll ledgers, W-2s, employer account information.
  • 02
    Fill core fields: Enter employer ID, reporting period, and wage totals.
  • 03
    Verify accuracy: Cross-check totals against payroll reports and tax filings.
  • 04
    Sign and submit: Authorized representative signs; send per Vermont DOL instructions.

Configure an electronic workflow for Form 25

A consistent digital workflow reduces errors. Use template fields and signer roles when preparing the form for eSubmission.

Field Configuration
Signature field Required; assign to employer authorized signer
Date field Auto-fill MM/DD/YYYY when signed
Authentication Email + SMS code recommended for identity
Template name Use consistent name like 'VT DOL Form 25 - Employer Report'

Typical submission flow for an employer report

This high-level flow shows the common path from preparation to departmental processing when submitting Form 25.

  • Prepare document: Populate form with payroll and event details
  • Authorize signer: Assign and authenticate the authorized representative
  • Submit to Vermont DOL: Send via DOL portal, mail, or authorized eSubmission method
  • Department processing: Vermont DOL validates, posts, and notifies employer

Digital delivery and integration considerations

Confirm file formats, signer authentication, and integrations before choosing an eSubmission path for Form 25.

  • File formats: Use PDF or DOCX for reliable rendering
  • Integrations: Link with payroll or HR systems like NetSuite
  • Authentication: Enable SMS or multi-factor for critical filings

Ensure your chosen platform supports required export formats, audit trails, and the Department's accepted upload methods to prevent rejection.

Security and compliance essentials for electronic handling

Encryption in transit: TLS 1.2/1.3 protected
Encryption at rest: AES-256 encrypted storage
Audit trail: Detailed timestamp and IP logging
HIPAA readiness: BAA available when required
Soc 2 compliance: SOC 2 Type II certified
ESIGN and UETA: Compliant with ESIGN/UETA rules

Common penalties and risks from incorrect filings

Late information returns: IRC §6721 penalties per form
Intentional disregard: IRC §6721 $660+ per form, no cap
I-9 and employment records: 8 CFR §274a.2 fines $281–$2,789
Audit exposure: Inaccurate reports increase audit risk
Processing delays: Missing employer ID causes rejections
Data breaches: Poor protection can trigger HIPAA/CCPA issues

Comparing eSignature vendors for filing forms like Vermont Form 25

Choose a vendor that supports audit trails, acceptable authentication, and any required compliance addenda. Pricing shown is plan starting price per user where available.

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 free trial No free trial Limited trial Limited trial
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
Envelope Cap No envelope cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Practical tips to complete Form 25 accurately

Adopt these practices to reduce errors, speed processing, and support audits or appeals related to Form 25 submissions.

Use a template
Create a vetted Form 25 template to standardize entries and reduce typos
Cross-check totals
Reconcile wage totals with payroll reports before submission
Validate IDs
Confirm employer account numbers and TINs match official records
Keep backup
Store signed copies and supporting records for the recommended retention period

Example scenarios illustrating common Form 25 uses

Real-world examples show how employers typically prepare and submit Form 25 in different operational contexts.

Small Employer Submission

A local retailer closes payroll week and needs to report a corrected wage total

  • They attach payroll export and sign
  • The Department accepted the corrected Form 25 after verification; retention maintained for three years to satisfy audits and tax reconciliation.

Payroll Service Provider

A payroll vendor completes Form 25 for multiple clients

  • Uses templates and bulk send functionality
  • Bulk digital workflows reduced turnaround time and standardized required authorizations across client employers, simplifying recordkeeping.

Frequently asked questions about Vermont Department of Labor Form 25

Answers to common procedural and technical questions encountered when preparing, signing, or submitting Form 25 to the Vermont Department of Labor.


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