Free Download Form 27 in PDF format - Vermont

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

DOL Form 27

Rev 7/07

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

www.labor.vermont.gov EMPLOYER'S NOTICE OF INTENTION TO DISCONTINUE PAYMENTS The Form 27 and supporting documentation must be received by the claimant and the Department of Labor at least 7 days before the actual discontinuance pursuant to § 643a. ATTACH SUPPORTING EVIDENCE. Employee Name: Employee Address: Effective Temporary total disability the following benefits will be DISCONTINUED for the reason(s) checked below. Temporary partial disability Medical benefits Vocational Rehabilitation Employer:

To the above name employee for the following reason(s): 1. Claimant has reached a medical end result. Report of Dr. attached. "End Medical Result" or "Medical End Result" is defined as "the point at which a person has reached a substantial plateau in the medical recovery process, such that significant further improvement is not expected, regardless of treatment". Claimant has been released for work with or with restrictions but has not made a reasonable effort to find such work OR has refused an offer of suitable work. Written documentation establishing the following must be attached: a. Medical documentation indicating the claimant has been released to return to work with or without restrictions attached; AND b. Written evidence showing that the claimant has been notified of the fact his/her release and his/her obligation to conduct a good faith search for suitable work OR to accept an offer of suitable work attached; AND c. Written explanation as to why you (the adjuster) feel the claimant has failed to make a reasonable effort to find suitable work attached; OR written documentation from the employer that shows they have suitable work but the claimant has refused such employment attached. Medical treatment is inappropriate or unrelated to work injury. Medical evidence attached. Specify treatment: No medical documentation supporting ongoing disability and/or treatment. Please attach a copy of your letter to medical provider and any response received, if you received no response please check here . Claimant has failed to attend a scheduled I.M.E. Carrier's scheduling letter, documentation of non-attendance and reason (if known) attached. Other (specify with attached evidence): REVIEWED BY:

2.

3. 4. 5. 6.

ISSUED BY:

Insurance Carrier

Date Notice Mailed

Insurance Adjuster (Print Name)

Date Reviewed

Insurance Adjuster Signature

Commissioner or Designee Signature NOTICE TO EMPLOYEE'S OF RIGHT TO APPEAL

IF YOU DISAGREE WITH THE NOTICE TO DISCONTINUE BENEFITS, you may request a hearing IN WRITING to the Department of Labor at the address above. ATTACH medical documentation and any other information to support your appeal. PLEASE BE SURE TO PUT YOUR STATE FILE NUMBER ON YOUR HEARING REQUEST.