DEPARTMENT OF LABOR - ATTN: WORKERS' COMPENSATION
PO Box 488
Montpelier, VT 05601-0488
(802) 828-2286
Form 1 (Rev. 9/11)
(Approved for use as OSHA 101 and 301)

 
State File No.

EMPLOYER FIRST REPORT OF INJURY
Answer every question fully and report promptly to avoid a penalty. Employer's Federal ID Number and Employee Social Security Number MUST be provided.

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1. Legal Name:
University of Vermont and State Agricultural College
2. Business Name:
University of Vermont and State Agricultural College
3. Mail Address: No. and Street
284 East Avenue
City               State        Zip
Burlington     VT        05405
4. Location (if different from Mail Address):
SAME
5. Telephone Number, Extension and Contact Person.:
Sarah Burnett - 802-656-0738
6. Nature of Business (list principal products or service of concern):
HIGHER EDUCATION
7. Do you regularly employ 10 or more employees
Yes No
8. Federal ID No.:
03-0179440
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9. Name: First Name
Middle Initial
Last Name
10. Social Security No.:
11. Date of Birth:
12. Home Address: No. and Street
13. Home Phone No.:
14. Work Phone No.:
15. Age:
City
State
Zip
16. Job Title:
17. Sex:
F
18. Wages $
Per:
Hours per day
Days per week
19. If board, lodging etc. were furnished in addition to wages, state estimated value:
$
20. Was employee hired in VT?:
N
21. Date of hire:
A
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22. Date of Accident
Accident Time 
AM  PM
Began shift 
AM PM
23. Location of Accident: Town or State City or Building
24. Machine, tool, object, motor vehicle or substance directly causing injury:
25. On employer's premises? N    If yes, name of department
26. Describe what employee was doing
Was this employee's regular occupation? N
27. How did accident occur?
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28. Describe the injury and part of the body injured
29. Was this a first-aid only injury
N
30. Any lost time?
N
If yes, date disability began
Last paid in full
31. Employee returned to work
N
If yes, date
Medical Only Incident
N
32. Did injury result in death?
N
If yes, date of death
33. Name and address of physician:
34. Name and address of Hospital: Remained overnightN
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35. Insurance Company Named on Workers' Compensation Policy
Name in full: Safety National Casualty Corporation(Excess Carrier)
Policy No. SP4046917
35A. Claim Administrator
Company Name CCMSI
Phone No. 802-864-3355
Signed by
 
                                                                                                                                                           
             Employer or Representative                                   Title                                   Date