21 V.S.A. § 658: Form of notice and claim

The notice and claim required under the provisions of section 656 of this title shall be in writing. Such notice shall contain the name and address of the employee; shall state in ordinary language the time, place, nature, and cause of the injury; and shall be signed by the employee or by a person in his or her behalf, or, in the event of his or her death, by any one or more of his or her dependents or by a person in their behalf. The notice and the claim may be combined.