Vermont Required Postings and Forms
The adjusting of the claims in this state is handled by Broadspire. Once a claim is reported to EMPLOYERS, the report will be sent to Broadspire for assignment. Below is the contact information for Broadspire:
P.O. Box 14133
Lexington, KY 40512-4133
Toll Free: 800-258-9546
Please post the following notices, both in English and Spanish, in a conspicuous location frequented by employees such as the break room, lunchroom or time clock. If you have multiple office locations be sure to post the notices at each location.
This notice must be posted in a conspicuous place upon your premises accessible to employees. This poster is available in alternative format. For further assistance, contact the Vermont Department of Labor, 802-828-2286.
- Safety Records Notice to Employees
- WC-9 Vermont Workers' Compensation Reinstatement Rights
- Anti-Fraud Notice (English and Spanish)
The following forms need to be completed and submitted to EMPLOYERS when a work-related injury occurs:
- First Report of Injury (FROI). As soon as you have been notified of a work-related injury, please immediately fill out this form and submit it to EMPLOYERS and provide a copy to the employee. Please use this form to notify EMPLOYERS of every work-related injury or disease suffered by an employee, regardless of severity.
- Wage Statement. This form enables us to calculate the correct compensation that may be owed to your injured employee. Please complete the form and submit it to EMPLOYERS when the employee is disabled for more than three scheduled work days. Also, provide a copy of the wage statement to the employee.
- Accident Investigation Report. This basic accident form should be completed by the employee’s supervisor/manager as soon as possible after the accident. Please send the report to the following EMPLOYERS address as soon as it has been completed by the supervisor/manager: EMPLOYERS Claim Department, P.O. Box 32036, Lakeland, FL 33802-2036. You should keep a copy on file for your records.
- Vermont Workers’ Compensation Medical Authorization. Title 21 VSA §655a requires all providers to utilize and comply with this medical release authorization form when seeking or providing medical information relative to a workers’ compensation claim. Workers’ Compensation claims are expressly exempted from the terms and provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR 164.512(1).
- Off-Site Transitional Duty Program - Helping Your Injured Employees Get Back to Work
A successful transition back to work relies on the collaborative efforts of the manager/supervisor, the injured employee and their adjuster. As a manager/supervisor, learn what you can do to help facilitate a successful return to work.