Departmental Forms

This page provides our downloadable Departmental Forms.

The forms are categorized by customer base employers, employees and youth.

If you do not see a form or need more information, 

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WORKERS COMPENSATION
Authorization to Release Medical Records
Used to disclose all medical records or other information regarding my treatment, hospitalization and/or outpatient.
Claim for Compensation on Account of Death
Used to claim compensation in the event of death.
Employee's Claim for Compensation for Disability
Used by employees to claim compensation for disability.
Conditions Governing Death Benefits
CLAIM FOR COMPENSATION ON ACCOUNT OF DEATH form should be completed and forwarded to this Office accompanied by the following documents.
Memorandum
Employer's Insurance Certificate
Employer's First Report and Employee's Notice of Injury or Occupational Illness
Used to provides information on the claimant, employer, insurance carrier and medical practitioner necessary to begin the claims process.
Standard Form for Surgeon's Report
Surgeon's Report.
EMPLOYER
Unemployment Insurance Business Status Change
Used to notify Unemployment Insurance of changes in legal form, closing of operations,transfers, or locale of operations.
Foreign Labor Certification Prevailing Wage Form
Used to fill out occupational wage data when hiring foreign worker(s)
New Hire Reporting
Used by employers to report hiring of new personnel.
Employee Wage and Contribution Report
Used to file unemployment insurance quarterly wage and hour contributions.
Worker Opportunity Tax Credit ETA 9061
Individual characteristics form used together with IRS 8850 to detemrine eligibilty for tax credit
Unemployment Insurance Employer Registration
Employer Registration for Unemployment Insurance
Worker Opportunity Tax Credit ETA form 8850
Application form used for obtaining Worker Opportunity Tax credit.
Foreign Labor Employment Form 750A
Application used to hire a foreign national Part A
Foreign Labor Employment Form 750b
Application used to hire a foreign national PartB
Multiple Worksite Report Form
The Multiple Worksite Report (MWR) form is used to collect employment and wages by individual work location in the Virgin Islands.
JOB SEEKER / EMPLOYEE
Wrongful Discharge Form
Complete this application if you believe that you were wrongfully discharged from your job.
Wage Claim
Used to file claim when there is an alleged violation of wage and hour laws
VICAN Intake Application (Unemployment Insurance)
Application for those seeking employment, unemployment benefits, or other services.
Employment Discrimination
Used by employee to file cliam of employment discrimination in the workplace.
YOUTH EMPLOYMENT OPPORTUNITIES
Summer Work Experience Application St. Croix District
Application for those seeking summer work experience in St. Croix
Summer Work Experience Application St. Thomas & St. John District
Application for those seeking summer work experience in St. Thomas/St. John
LIFT 2016 Application
Labor Investing For Tomorrow application. Deadline to apply is March 25, 2016.
Summer Employment Employer Request Form
Providers, please use this form to request students for the Summer Work Experience Program
Summer Employment Fact Sheet
This fact sheet will let you know what documents you will need to attach to your work experience application as well as other meaningful information.
Summer Work Experience Customer Manual
Customer manual for those participating in the Summer Youth Work Experience Program
SUMMER YOUTH PROVIDERS
Mentorship Application
Instructions and application for those Providers that are interested in our mentorship training programs.
Summer Youth Workshop Application
Guidelines and application for providers interested in participating in our Life Skills and Career Exploration Summer Workshops for 14 & 15 year olds.
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