Free Download Form 23 in PDF format - Vermont

DOL FORM 23 State File No. Ins. Co. File No.

(Rev. 5/05)

DEPARTMENT OF LABOR WORKERS' COMPENSATION DIVISION

Date of Injury Fed. ID No.

AGREEMENT FOR COMPENSATION IN FATAL CASES IT IS AGREED, between of the dependents of , the deceased employee of , **spouse, ** reciprocal beneficiary, **dependent, *guardian

Street,

Rural Route,

Box Number,

AND
City, State, Zip

, the **insurance carrier/**employer,

By reason of the fatal accidental injury suffered on of the city/town of causing the following injury: from which death resulted on , 20

, 20

, by the said employee while in the employ of , in the County of and State

MEDICAL, HOSPITAL AND SURGICAL SERVICES
That the employee shall receive medical, hospital, surgical and nursing services and supplies in accordance with the provisions of 21 V.S.A. § 640. The expense of such services and supplies shall be borne by the insurance carrier/employer.

BURIAL EXPENSE
It is agreed that the deceased employee's burial expense shall be borne by the **insurance carrier/**employer, in accordance with the provision of 21 V.S.A. § 632, as amended.

DEPENDENTS
It is agreed that the following persons were dependent upon the deceased employee for support and by reason of his /her death are entitled to compensation as provided by law:
Name Relationship Date of Birth

WEEKLY COMPENSATION
It is agreed that the employee's average weekly wage for the twelve weeks before the injury was dependents are entitled to beginning % (percent) of said average weekly wage, the sum of , 20 $ $ and that said and that said

and continuing until a change in the condition of dependency occurs, after which the amount

due weekly shall be redetermined. The period of payment shall not exceed the limits set forth in 21 V.S.A. § 635, as amended.

APPROVAL AND REVIEW
This agreement or any settlement thereunder shall not be binding or operative unless and until this agreement and such settlement is approved by the Commissioner of Labor.

Insurance Adjuster Name (Print)

Spouse, Reciprocal Beneficiary, Dependent or Guardian of Dependents

Insurance Adjuster Signature Official Title Date Date

APPROVED: **Strike out inappropriate expressions.

, 20 Commissioner of Labor/Designee