Vermont > Workers Compensation
Settlement Agreement 16 - Vermont
| Settlement Agreement Form. This is a Vermont form and can be used in Workers Compensation . |
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Department of Labor Workers' Compensation Division 5 Green Mountain Drive, PO Box 488 Montpelier, VT 05601-0488 SETTLEMENT AGREEMENT Attach any additional conditions, terms, etc. The injured worker DOL Form 16 (Rev. 9/11) Replaces Former Form 14 and Form 15 State File #: Ins. Co.. File # Date of Injury whose address is: , and **insurance carrier **employer on ,20 causing the following injury: and resulting in: temporary total disability medical only agrees that a work injury occurred while worker was employed by temporary partial disability permanent partial disability permanent total disability Beginning on: ,20 $ (insurer must have filed a wage statement) , in full and final settlement of : That the employee's average weekly wage before the accident was This is an agreement in which the claimant agrees to accept (list benefits being closed out indemnity, medical, VR, etc.) sustained as a result of the accident referred to above. $ It is agreed that the carrier will continue to furnish: All reasonable past, present and future medical, hospital, surgical and nursing services and supplies necessary for the treatment of this injury. Other (describe): If payment is to be in a lump sum please complete one of the paragraphs below: Claimant agrees to accept and the employer/carrier agrees to pay a lump sum of $ . This lump sum is compensation for permanent impairment that will affect the claimant for the rest of his/her life. The claimant's remaining life expectancy is years or months. Therefore, even though paid in a lump sum, claimant's benefit (after deduction of attorney fees of and expenses of ) shall be considered to be $ per month beginning on the date of approval of this settlement OR Claimant agrees to accept and the employer/carrier agrees to pay a lump sum of $ . Claimant expressly requests that the lump sum not be prorated as otherwise required by 21 VSA §652(c). APPROVAL AND REVIEW This settlement shall not be binding or operative until it is approved by the Commissioner of Labor or designee Dated at this day of ,20 Insurance Carrier or Employer By Employee Official Title APPROVED: ,20 Commissioner of Labor/Designee American LegalNet, Inc. www.FormsWorkFlow.com
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