VSBIT - Vermont School Boards Insurance Trust

WORKERS' COMPENSATION CLAIM ENTRY:

Did employee seek medical attention?	Yes No
Did employee lose time from work?	Yes No
Did the employee's injury involve the back, knee or shoulder?	Yes No

This injury is not a reportable WC injury.
You may continue and report it as an incident only (not required)
or you may exit out.

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Employer Section

Employee Section

First Name

Last Name

Address 1	Address 2
City	State	Zip

Home Phone #

() -

SSN	Gender	Date of Birth
Job Title	Employment Location	Date of Hire

Accident Section

Date of Accident	Date Reported to Employer	Time of Accident	Shift Started at
Location of Accident		Town / City	State
On Employer's Premises? Yes No		If yes, please specify exact location (ex: ABC school playground)
Machine or tool involved in accident
Was it defective? Yes No		If yes, describe how
Object or substance directly causing injury

Injury Section

Describe in detail the injury and the part of body injured
Any lost time from work? Yes No	If yes, date disability began	Last date paid in full
Employee returned to work? Yes No	If yes, date returned
Did injury result in death? Yes No

Medical Treatment

Important Note: Please list only those physicians or hospital/clinics
employee has utilized for this work related injury.

Name and address of all treating physicians/hospital/clinics, etc.

This notice was submitted by:
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