Vermont > Workers Compensation
Agreement For Temporary Total Disability Compensation 21 - Vermont
| Agreement For Temporary Total Disability Compensation 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 (802) 828-2286 DOL Form 21 Rev 6/10 State File No.: Ins. Co. File No.: Date of Injury; Agreement for Temporary Total Disability Compensation IT IS AGREED, between , the employee, whose present mailing address is: Street, Rural Route, Box Number, City, State, Zip AND an accident while in the employ of state of , the insurance carrier/employer that on of the city/town of causing the following injury: the employee suffered and resulting in temporary total disability beginning on: WEEKLY COMPENSATON RATE The employee is entitled to a weekly compensation rate of two-thirds (66.667%) of his/her average weekly wage not to exceed his/her weekly net income. S/he is further entitled to an additional $10.00 per week for each dependent child under 21 years of age provided that the total weekly compensation not exceed the employee's weekly net income. A. B. C. D. Claimant's Average Weekly Wage Weekly Compensation Rate (66.667% of A.W.W.; Weekly Net Income; Minimum or Maximum Rate) Number of Dependents multiplied by $10.00 Total Weekly Compensation Rate DISABILITY Beginning on the fourth day of disability, the the employee shall receive compensation at said rate. day of and continuing during the period of total disability, A. B. C. D. $ $ $ $ Day of the week the check will be mailed to the claimant or deposited in the claimant's account EMPLOYEE OBLIGATION TO REPORT WORK AND EARNINGS Temporary Total Disability compensation is provided only where an injury causes total disability from any work. By signing this agreement the employee is stating that he or she is not currently working, and that he or she is obligated to report promptly any work earnings, wages or benefits to the insurance carrier/employer and the department. Insurance Adjuster Name (Print) Employee Name (Print) Insurance Adjuster Signature Date Employee Signature Date APPROVED: Date Commissioner of Labor/Designee American LegalNet, Inc. www.FormsWorkFlow.com
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