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When a workers' compensation claim involves lost work time, the employer needs to report the claimant's wages for all of the 26 weeks immediately before the injury by completing the Vermont Department of Labor's Workers' Compensation Wage Statement. Even though this form has some built-in instructions, PACIF claims adjusters have found that more detailed explanation is often needed before the form will meet the state's requirements.

Click on the image or on the file under Documents below to download the PDF of this explanatory resource. After using it, if you have any questions or problems completing the state’s WC Wage Statement, please call or email your VLCT PACIF adjuster.

Image of Vermont Department of Labor's "Form 25" with instructive callouts about what information needs to be provided

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