Free DOL FORM 13 (Rev - Vermont

DOL FORM 13 (Rev. 5/05)

State File No. Ins. Co. File Date of Injury Fed. ID No.

DEPARTMENT OF LABOR WORKERS' COMPENSATION DIVISION

REPORT OF BENEFITS AND RELATED EXPENSES PAID
EMPLOYEE: EMPLOYER: INS. CARRIER: ADJUSTING CO. (if different from carrier): REPORT TOTAL EXPENSES PAID TO DATE FOR THIS CLAIM. Date Completed. VOCATIONAL REHABILITATION Contractual (VR Vendor) LEGAL - Defense (Contractual) MEDICAL TEMPORARY TOTAL DISABILITY
From From To To @ $ @ $ Total Weeks Total Weeks Days Days $ $
(h) (j) (a) (c) (e)

SOCIAL SECURITY NO.: NCCI CLASS CODE: CONTACT PERSON:

(b) (d) (f) (g)

Benefits Paid Plaintiff (Lien)

$ $ $

(i) (k) (l)

$

(m)

TEMPORARY PARTIAL DISABILITY
From From To To @ $ @ $ Total Weeks Total Weeks Days Days

$

(n)

PERMANENT PARTIAL DISABILITY
LUMP SUM ADVANCES From To Date @ $ Amount $

Total Weeks

$

(o)

PERMANENT TOTAL DISABILITY
From From To To @ $ @ $ Total Weeks Total Weeks

$

(p)

FATALITY (Spouse/Dependent Benefits)
From To @ $ Total Weeks

$ $

(q) (r) (s)

FUNERAL (Including payment to the 2nd Injury Fund, if appropriate) SETTLEMENT AGREEMENTS (Check One) 14 15 16

$

EACH BLANK MUST BE COMPLETED. USE N/A WHERE APPROPRIATE.