Free Download Form 28 - FY03 in Adobe 9 Fill In Format - Vermont

DOL FORM 28 State File No. Ins. Co. File No.

FY-03 Rev 5/05

DEPARTMENT OF LABOR WORKERS' COMPENSATION DIVISION www.labor.vermont.gov

Date of Injury Fed. ID No. Social Sec. No.

NOTICE OF CHANGE IN COMPENSATION RATE
(for INJURIES AFTER JULY 1, 1986) RE:
(Employee)

v.
(Employer)

Check type of agreement involved:

Temporary Total Temporary Partial

Permanent Total Permanent Partial

Fatal

1.

Write in the employee's compensation rate effective June 30, 2002. (Not including dependent's benefits.) $

2.

Multiply line 1 by 1.044 and write in the result, but not more than the maximum rate of $865 or less than the minimum of $288. (see REMINDER below) ANY CLAIM WHERE THE EMPLOYEE RECEIVED THE MAXIMUM ON JUNE 30, 2002, THE NEW MAXIMUM SHALL BE ENTERED HERE SUBJECT TO EMPLOYEE'S AVERAGE WEEKLY WAGE.

$

3.

For Temporary Total Disability cases ONLY, multiply the number of dependents under the age of 21 by $10 and write in the result. Write in the TOTAL of lines 2 and 3. This is the new compensation rate for the year beginning July 1, 2002.

$

4.

$

REMINDER:

FOR INJURIES AFTER JULY 1, 1994, THE COMPENSATION RATE CANNOT EXCEED THE WEEKLY NET INCOME.

Maximum rate is $865 and the minimum rate is $288 (not including dependent's benefits) for the year beginning July 1, 2002. This is an amendment to the original Temporary Total, Temporary Partial, Permanent Partial, Permanent Total, or Fatal agreement.

Insurance Company or Self-Insured

Date

Claims Adjuster's Signature

Title

Commissioner of Labor/Designee

Date

Instructions to insurance company or self-insurer: Complete above. Increase the weekly compensation rate beginning July 1, 2002. File three (3) copies with the Department of Labor before July 15, 2002. After the change has been approved, provide copies 2 and 3 to the carrier and the claimant.