Free Download Form 21 in Adobe 9 Fill In Format - Vermont

DOL Form 21

Rev 5/05

DEPARTMENT OF LABOR WORKERS COMPENSATION DIVISION 5 GREEN MOUNTAIN DRIVE, PO BOX 488 MONTPELIER, VT 05601-0488 (802) 828-2286
www.labor.vermont.gov

State File No.: Insurance Co. File No.: Date of Injury: FEIN: Soc. Sec. No.

AGREEMENT FOR TEMPORARY TOTAL DISABILITY COMPENSATION
IT IS AGREED, between , the employee, whose present mailing address is:

Street, Rural Route, Box Number, City, State, Zip

AND an accident while in the employ of state of

, the insurance carrier/employer, that on of the city/town of

the employee suffered

causing the following injury:

and resulting in temporary total disability beginning on

WEEKLY COMPENSATION RATE
The employee is entitled to a weekly compensation rate of two-thirds (66.667%) of his/her average weekly wage not to exceed his/her weekly net income. S/he is further entitled to an additional $10.00 per week for each dependent child under 21 years of age provided that the total weekly compensation not exceed the employee's weekly net income.

A. B. C. D.

Claimant's Average Weekly Wage Weekly Compensation Rate (66.667% of A.W.W.; Weekly Net Income; Minimum or Maximum Rate) Number of Dependents multiplied by $10.00 Total Weekly Compensation Rate DISABILITY

A. B. C. D.

$ $ $ $

Beginning on the fourth day of disability, the

day of

,

and continuing during the period of

total disability, the employee shall receive compensation at said rate.

EMPLOYEE OBLIGATION TO REPORT WORK AND EARNINGS Temporary Total Disability compensation is provided only where an injury causes total disability from any work. By signing this agreement the employee is stating that he or she is not currently working, and that he or she is obligated to report promptly any work, earnings, wages or benefits to the insurance carrier/employer and the department.

Insurance Adjuster Name (Print)

Employee Name (Print)

Insurance Adjuster Signature
APPROVED:

Date

Employee Signature

Date

Date

Commissioner of Labor/Designee