Free Download Memorandum of Payment in Adobe 9 Fill In Format - Vermont

www.labor.vermont.gov

STATE OF VERMONT DEPARTMENT OF LABOR & INDUSTRY WORKERS COMPENSATION DIVISION 5 GREEN MOUNTAIN DRIVE, PO BOX 488 MONTPELIER, VT 05601-0488 (802) 828-2286

Form 25M State File No.: Insurance Co. File No.: Date of Injury:

Rev 8/07

This form shall be filed whenever a claimant is eligible to receive more than 90 calendar days of continuous temporary total disability benefits (see Rule 53.1100). Failure to file this form promptly and accurately may result in administrative sanctions pursuant to Rule 45.000.

MEMORANDUM OF PAYMENT
Employee
Last Name: Mailing Address Telephone Number First Name: City State Zip

Employer
Employer Name Insurer Employer Telephone Number

Payment Made
Weekly Compensation Date Disability Payment Began: Total Amount of Indemnity Paid To Date: Other: (Please Explain) Weekly Amount Paid:

ISSUED BY:
Carrier: Adjuster Name: Adjuster Signature: Adjuster License #: Administrator (if not carrier): Telephone No. Adjuster's Employer:

Company Responsible for Payment: Mailing Address City State Zip