Free Download Form 24 in PDF format - Vermont

DOL FORM 24 State File No. Ins. Co. File No. Date of Injury Fed. ID No.

(Rev. 5/05)

DEPARTMENT OF LABOR WORKERS' COMPENSATION DIVISION

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

Street,

Rural Route, Box Number,

City,

State,

Zip

AND suffered an accident while in the employ of state of

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

, 20

the employee

causing the following injury: and resulting in temporary total disability beginning on , 20 .

WEEKLY COMPENSATION RATE
The employee's average weekly for the twelve weeks before the accident was $ $ $ and that he/she has weekly earnings of per week.

and he/she is entitled to temporary partial compensation of

**Maximum and minimum weekly compensation rates are set annually by a self-adjusting formula. New rates are effective July 1 of each year and apply to accidents which occur between that date and July 1 of the following year. New rates are adopted and published annually by the Commissioner of Labor during the month of May.

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

TEMPORARY PARTIAL DISABILITY
Beginning the 8 day of temporary partial disability or at the end of temporary total disability, on the the employee shall receive compensation at said temporary partial rate.
th

day of

, 20

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, and is subject to review by said Commissioner upon their own motion or on motion of either party upon the ground of a change in physical condition of the employee entitled to compensation hereunder.

Insurance Adjuster Signature

Employee Signature

Date

Official Title

Date

Social Security Number

APPROVED:
Date Commissioner of Labor/Designee