University of Vermont

Department of Risk Management & Safety

Insurance and Claims Management

Worker's Compensation Claim Forms:

A Guide to Filing a Worker's Compensation Claim

What is Covered by Worker's Compensation

Medical expenses related to the treatment of your work related injury or illness are covered under worker's compensation. This includes doctor, hospital, physical therapy, prescription medication and equipment. Alternative treatment such as massage therapy and acupuncture must be pre-approved.

Worker's compensation will pay for wages lost as a result of your injury or illness. Your absence must be related to your work injury and authorized by your doctor. Compensation is determined according to State statute and is subject to a three day waiting period. Worker's compensation disability payments are approximately two thirds of your average weekly wage and are non taxable income.

If you are unable to return to your pre-injury job after recovering from your work related injury or illness, you may be determined eligible for vocational rehabilitation services.

Worker's Compensation: How it works

When an Employer's First Report of Injury is received by Risk management, the copies are distributed as appropriate. The original is sent to Labor and Industry as required by law.

Cannon Cochran Management Services, Inc. (CCMSI) is the University's claims adjustment service. They investigate all claims and determine whether or not to accept a claim. CCMSI also processes payments for medical expenses and disability payments for work time lost.


The claim is set up to make payment for any medical expenses related to the injury or illness. The employee should tell the health care provider to send the bills to Risk Management for payment under worker's compensation.


The absence must be authorized by the employee's treating professional. The employee must be out of work for three days (excluding the day of injury) before worker's compensation pays for work time lost. The three day wait includes weekends and holidays. Disability payments are calculated as follows:

If the employee loses 1-3 days of work, no temporary disability payments will be made.

If the employee loses 4-9 days, temporary disability will begin with day four. At this point in time, University policy states that the Department will credit back accrued leave used for the 3 day waiting period, only if the employee becomes eligible for worker's comp disability (is out of work four or more days). Therefore, if the employee is out more than four days, s/he is paid by Worker's Compensation beginning with day 4, and the Department pays for the first 3 days the employee is out.

If the employee is out 10 consecutive days or more, Worker's Compensation disability payments will begin with day one of the absence.

The temporary disability payments are based on the wages the employee earned in the 12 weeks prior to the date of injury. The rate is 2/3 of this wage, plus $10 per week, per dependent. The payments are tax-free and subject to limits set by the state.

If the employee has medical leave and/or vacation leave accrued to cover the time s/he is out of work, it is suggested that they use accrued leave. Worker's comp disability payments will be sent to the Department and used to buy back as much of the medical or vacation time as possible. (amount of check divided by hourly wage = hours of leave brought back) The employee continues to be paid by the University and leave continues to accrue. If the employee does not have accrued leave, worker's comp disability payments will be sent from Cannon Cochran Management Services, Inc. (CCMSI) to them. If the employee does not receive a University paycheck, medical and vacation leave does not accrue. No payment will be made until the claim has been investigated and accepted under worker's compensation. If an employee is in this situation, please let Risk Management know so every effort can be made to expedite processing and investigation of the claim.


The employee must get a note for his/her doctor stating that s/he can return to work.

If the employee can return to work on a part time basis, Worker's Comp will cover the time they cannot work and the Department pays for the time the employee can work, for a total not to exceed 2/3 of their gross pay.

If the employee has follow-up appointments related to the injury or illness, the employee's medical leave should not be used for the time away from work. The employer (your department) bears the cost associated with absence related to follow up medical care. The employee must notify the supervisor of the appointment as far in advance as possible, and should try to schedule appointments at a time they will have the least impact on the function of the department. If necessary, the supervisor can request written verification of the appointment from the employee.

Common Questions

Why is completion of an employer's First Report of Injury necessary? Do I need to report minor injuries?

Employers are required by law to report work related injuries to the Department of Labor and Industry via the Employer's First report of Injury form. The First Report also protects the employee. What you may consider a minor accident now, could develop into a major problem a few weeks, or months, later. Report ALL on the job injuries to your supervisor as soon as possible.

Who is responsible for completing the employer's First Report of Injury? When should it be completed?

The law considers notification to a supervisor sufficient notice to the employer. THE SUPERVISOR IS THE EMPLOYER. The employee has a responsibility to report the injury, and assist the supervisor in completing the Employer's First Report. This must be done as soon as possible after discovery of a work related injury or illness. Labor and Industry guidelines state that the injury must be reported within 72 hours, subject to a penalty for late notification.

Why do I have to reveal confidential information such as my wages, social security number and physician's name and address? Is it necessary to sign a medical authorization form in order to file a worker's compensation claim?

Some of this information is necessary for identification and statistical purposes. If your injury is serious enough to warrant medical attention, this needs to be communicated on lines 34 and/or 35 of the Employer's First Report. In this way, your claim is set up for payment of expenses related to your injury prior to the receipt of bills. This helps to facilitate prompt payment to your provider. If you did not seek medical attention indicate this on line 34. The First Report will be kept for record purposes. The medical authorization form is necessary to verify with your doctor that your injury is work related and the charges submitted for payment are related to your injury. Only information pertaining to your injury will be requested. All records received from your doctor are considered confidential and are treated as such. Your doctor will not release any medical records without your authorization. No payments can be made for medical bills or work time lost without the signed medical authorization.



If you have a work-related injury or illness (a condition that develops over time, such as carpal tunnel syndrome or tendinitis) you must do the following:

1. NOTIFY YOUR SUPERVISOR as soon as possible and assist him or her in completing an Employer's First Report of Injury. Send the completed form to Risk Management. Risk Management must send the Report to the Department of Labor and Industry within 72 hours of the date of injury, subject to penalty for non-compliance.

2. TELL YOUR DOCTOR THAT YOU WERE INJURED ON THE JOB. Medical bills should be sent to Risk Management for payment under worker's compensation (not your health insurance plan). Receipts for out of pocket expense, such as prescription medication and equipment, should be sent to Risk Management for reimbursement under worker's compensation.

3. IF YOU ARE UNABLE TO WORK AS A RESULT OF YOUR INJURY, NOTIFY YOUR SUPERVISOR. Keep your supervisor informed of your progress and anticipated return to work date. You must provide your supervisor and Risk Management with a doctor's note which authorizes your absence from work.

4. IF YOU ARE ABLE TO WORK PART TIME OR CAN WORK WITH TEMPORARY JOB MODIFICATION please notify your supervisor and Risk Management. A Temporary Modified Duty Work Agreement must be completed. This agreement specifies your doctor's restrictions and temporary work assignment as well as the time period your doctor recommends the restrictions should remain in place.

5. ADDITIONAL FORMS AND CONTACT WITH THE INSURANCE ADJUSTOR may be necessary. Your claim is subject to investigation by the University's insurance adjustor. Complete all requested forms and return them to Risk Management as quickly as possible.

Supervisor's Responsibilities for Filing Worker's Compensation Claim

1. COMPLETE THE EMPLOYER'S FIRST REPORT OF INJURY AND SEND IT TO RISK MANAGEMENT AS SOON AS POSSIBLE. Risk Management must send the form to Labor and Industry within 72 hours of the report of injury. As the supervisor, YOU are the employer. The employee has the responsibility to report the injury or illness and assist the supervisor in completing the Employer's First Report of Injury. If the employee is unable to assist you, complete the form to the best of your ability. An employee has six months from the time an injury is known to be work related to report it, one year for an illness (such as carpal tunnel syndrome).

2. COMMUNICATE WITH RISK MANAGEMENT. Call the claims specialist if your employee is unable to work, or when they return to work, following a work related injury or illness. If you have information relative to the investigation of a worker's compensation claim, notify the claims specialist.

3. COMMUNICATE WITH YOUR EMPLOYEE. Ask how they are doing, when they expect to come back to work, and keep them involved with what's happening at work. Statistics indicate this contact with the work place can assist the employee in recovering from an injury or illness.

4. CONSIDER PROVIDING TEMPORARY MODIFIED DUTY WHICH WILL ALLOW YOUR EMPLOYEE TO RETURN TO WORK. Often, an employee who is unable to perform their usual work tasks can work in some capacity. View the necessary work tasks with a creative eye, or identify special projects the employee may be able to work on. Consider allowing your employee to return to work on a part time basis.


Employer's First Report of Injury available from Risk Management at 656-3242, or link to it here.


Please feel free to call Risk Management at 656-3242 with any questions you may have.

Last modified May 23 2018 07:39 AM

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