All of the Department of Labor’s forms will be in PDF format. If you do not have a PDF reader, you can download a free one from Adobe.
- Unemployment Insurance Forms
- Tramway Forms
- Wage & Hour Forms
- Workplace Safety Forms
- Workers’ Compensation Forms
- Vocational Rehabilitation Forms
Wage & Hour Forms
- File On-line Wage Claim
- Wage Claim Form [PDF]
- Wage Complaint Form [PDF]
- Child Labor Certificate [PDF]
Workplace Safety Forms
Tramway Forms
- Lift Registration Form [PDF]
- Renewal Application for Tramway Registration [PDF]
- Tramway Incident Report [PDF]
- Wire Rope Inspection Form [PDF]
- Dynamic Test Form [PDF]
Unemployment Insurance Forms
Claimant Forms:
- Disaster Unemployment Assistance [PDF]
- B-1 Return to Work Notification [PDF]
- B-2 Claimant Change of Name and Address [PDF]
- B-11 UI Claimant Handbook [PDF]
- B-12 UI Claimant Appeal Form [PDF]
- B-18 Guide to Filing a weekly claim the internet [PDF]
- B-23 Unemployment Insurance and You [PDF]
- B-37 Promise of Full-Time Employment [PDF]
- B-38 Direct Deposit Form [PDF]
- B-82 Claimant Work Search Report [PDF]
- B-114 One-Stop Center Websites for Claimants who Relocate Out-of-State [PDF]
- B-154 Responsibilities and Rights [PDF]
- BAM-14 Information for Claimants [PDF]
- D-11 Proper reporting of gross wages [PDF]
- D-250 Report of Suspected UC Fraud [PDF]
Employer Forms:
UI Employer Forms:
- Employer Information Manual [PDF]
- Employer Manual Updates [PDF]
- Employee Leasing Companies [PDF]
- A-24 Unemployment Insurance Poster [PDF]
- B-13 UI Employer Appeal Form [PDF]
- B-14 Employer Appeal of Tax Liability [PDF]
- BAM-17 Benefit Accuracy Measurement Information [PDF]
- C-1 Status Report [PDF]
- C-29 Third Party On-Line Reporting Specifications [PDF]
- C-29A Large Employer Quarterly C-101 Wage & Contribution Report On-line Application [PDF]
- C-30 Employer Packet Welcome Letter [PDF]
- C-49 Memo of Understanding [PDF]
- C-36 Notice of Change [PDF]
- C-50 Power of Attorney [PDF]
- C-61 New Hire Reporting Form [PDF]
- C-63 New Hire Reporting Requirements [PDF]
- C-101 Quarterly Contribution Report & Instructions [PDF]
- C-102 Employer’s Amended Quarterly Report Form [PDF]
- C-104 VITWS Upload Specifications [PDF]
- C-147 Employer Quarterly Wage Report & Instructions [PDF]
- D-250 Suspected Fraud Report [PDF]
- F-34E Work Available Report [PDF]
- F-35 Refusal of Work Report [PDF]
- Mass Layoff Template spreadsheet [XLSX]
Employer Health Care Reporting Forms
- HC-1 Health Care Contribution Worksheet [PDF]
- HC-2 Declaration of Coverage [PDF]
- HC-3 A Guide to Health Care Reporting [PDF]
- HC-4 Health Care Decision Tree [PDF]
STC Employer Forms
- Explanation of STC Program (B-3) [PDF]
- Participant Info (B-102) [PDF]
- Application A (B-148) [PDF]
- Application B (B-146) [PDF]
- Initial Claim Form (B-65) [PDF]
- Weekly Claim Form (B-6) [PDF]
- Weekly Employer Report (B-145) [PDF]
- Process Upon Approval (B-153) [PDF]
Employee Leasing Forms
- EL-1 Employee Leasing Licensure & Company Registration Application [PDF]
- EL-2 Authorizing Individual Affidavit [PDF]
- EL-3 Security Bond Form [PDF]
- EL-4 Memorandum of Understanding Letter of Credit [PDF]
- EL-5 Employee Leasing UI Requirements [PDF]
- EL-6 List of Vermont Clients [PDF]
- EL-7 Employee Leasing “How to Apply” [PDF]
Workers’ Compensation Forms
Workers’ Compensation Forms
- Payment Scheduling Clarification Guidance Document [PDF]
- Form 1 – Employee’s Claim & Employer’s First Report of Injury – Last Revised 9/11 [PDF]
NOTE: The injured employee must receive a Form 8 and a completed copy of Form 1 ~ Email First reports to Labor.WCFirstReport@vermont.gov - First-Aid Only Injuries and Deductible Policies [PDF]
- Form 2 – Denial of Workers’ Compensation Benefits – Last Revised 5/2016 [PDF]
- Form 4 – Report of Fatal Accident – Last Revised 9/11 [PDF]
- Form 5 – Employee’s Notice of Injury and Claim for Compensation – Last Revised 9/11 [PDF]
You can also contact Paul Donovan at (802) 828-2994 or Paul.Donovan@vermont.gov for further information. - Form 6 – Notice and Application for Hearing – Last Revised 9/11 [PDF]
- Form 7 – Medical Authorization – Last Revised 1/17 [PDF]
- Form 8 – Notice of Intent to Change Health Care Provider – Last Revised 9/11 [PDF]
- Form 10 – Certificate of Dependency and Concurrent Employment – Last Revised 9/11 [PDF]
- Form 13 – Report of Benefits and Related Expenses Paid – Last Revised 9/09 [PDF]
- Form 13A – Aggregate Annual Reporting Form – Reporting Period 7/1 through 6/30 – Last Revised 8/16 [PDF]
- Form 16 – Settlement Agreement – Last Revised 7/14 [PDF]
- Form 20 – Work Capabilities Form – Last Revised 12/10 [PDF]
- Form 22 – Agreement for Permanent Partial Disability Compensation – Last Revised 6/10 [PDF]
- Form 23 – Agreement for Compensation in Fatal Cases – Last Revised 6/10 [PDF]
- Form 25 – Wage Statement For injuries ON OR AFTER July 1, 2008- Last Revised 9/13 [PDF]
- Form 25 – Wage Statement For injuries BEFORE July 1, 2008- Last Revised 9/13 [PDF]
- Form 25M – Memorandum of Payment – Last Revised 1/15 [PDF]
- Form 25s – Weekly Net Income Worksheet – Last Revised 9/09 [PDF]
- Form 27 – Notice of Intention to Discontinue Payments – Last Revised 5/16 [PDF]
- Form 28 – Notice of Change in Compensation Rate for Injuries after 7/1/86 – Last Revised 6/13
Historical Rates
Fiscal Year 2017 [PDF]
Fiscal Year 2016 [PDF]
Fiscal Year 2015 [PDF]
Fiscal Year 2014 [PDF]
Fiscal Year 2013 [PDF]
Fiscal Year 2012 [PDF]
For prior years please contact the Department at (802) 828-2286 or
Labor.WCComp@vermont.gov - Form 28a – Notice of Change in Compensation Rate for Injuries before 7/1/86 – Last Revised 6/13
Historical Rates
Fiscal Year 2017 [PDF]
Fiscal Year 2016 [PDF]
Fiscal Year 2015 [PDF]
Fiscal Year 2014 [PDF]
Fiscal Year 2013 [PDF]
Fiscal Year 2012 [PDF]
For prior years please contact the Department at (802) 828-2286 or
Labor.WCComp@vermont.gov - Form 29 – Application for Exclusion from the Provisions of the Workers’ Compensation Act – Last Revised 2/13 [PDF]
- Form 30 – Application for Self-Insurance – Last Revised 4/16 [PDF]
- Form 31 – Notice to Employees: Employer’s Liability and Workers’ Compensation – Last Revised 12/05 [PDF]
- Form 32 – Agreement for Temporary Compensation – Last Revised 6/14 [PDF]
- Form VR227 – Vocational Rehabilitation Denial/Discontinuance – Last Revised 9/11 [PDF]
- Bond Form for Self-Insured – Last Revised 6/05 [PDF]
- Assumption and Guarantee Form [PDF]
- Self-Insurer’s Report [PDF]
- Workers’ Compensation Assessment Forms and Information
- Report of Employer Conducting Business Without Workers’ Compensation Insurance
- Report of Suspected Workers’ Compensation Insurance Fraud
- Medical Provider Preauthorization Form
- Workers’ Compensation Alternative Dispute Resolution Report [PDF]
This report must be filed within 15 days of completion of the mediation. If you want to submit this form electronically please save it and attach it to an e-mail to Phyllis Phillips at phyllis.phillips@vermont.gov.
Vocational Rehabilitation Forms
- Form 25M – Memorandum of Payment [PDF]
- Vocational Rehabilitation Annual Survey [PDF]
- Vocational Rehabilitation Referral Form – Revised 9/2013 [PDF]
- Vocational Rehabilitation Cover Page [PDF]
- Vocational Rehabilitation Discontinuance Report [PDF]
- Vocational Rehabilitation Entitlement Assessment [PDF]
- Vocational Rehabilitation Return to Work Plan [PDF]
- Vocational Rehabilitation Progress Report [PDF]
- Vocational Rehabilitation Disclosure Statement [PDF]
- Notice of Intention to Change Vocational Rehabilitation Provider – Updated 8/2013 [PDF]
- Certified Vocational Rehabilitation Counselors [PDF]
- Vocational Rehabilitation Self-Employment Workbook [PDF]
- Application for Certification as a Vermont Rehabilitation Professional [PDF]
- Download Renewal Application for Certification as a Vermont Rehabilitation Profession [PDF]