Certificate Of Dependency And Concurrent Employment {10}

FORM 10 - CERTIFICATE OF DEPENDENCY AND CONCURRENT EMPLOYMENT. This form issued by the Vermont Department of Labor, is used in workers’ compensation cases when an employee has lost time from work due to a work-related injury. This form must be completed by the injured worker, even if they have no dependents. It collects essential information to determine whether the worker is eligible for additional weekly compensation—specifically, $20.00 per week for each dependent child under the age of 21 who has not already been claimed by a spouse on a separate workers’ compensation claim. The form documents any concurrent employment, meaning any other jobs the worker held on the date of the injury. The worker must list these employers, including contact details and the date of hire. By signing the form, the employee certifies that the information provided is accurate and complete. www.FormsWorkflow.com