If you have been injured at work and your employer has failed to file a First Report of Injury you may file WRITTEN NOTICE of your claim or of the benefit you are requesting by filing a Form 5 Employee's Notice of Injury and Claim for Compensation.
Specify in your Form 5 the date of your work injury, your address, your employer, and the benefit(s) you are seeking.
You can download the Form 5 in PDF format by clicking here. If you do not have Adobe PDF you can click here and download a free reader.
If you have any questions or need assistance with the form please contact the Ellen Gonyaw of the Workers' Compensation Division at (802) 828-2286.
Send your Form 5 Notice to:
Workers’ Compensation Division
Vermont Department of Labor
PO Box 488
Montpelier, VT 05601-0488