Vermont > Workers Compensation
Denial Of Workers Compensation Benefits By Employer Or Carrier 2 - Vermont
| Denial Of Workers Compensation Benefits By Employer Or Carrier Form. This is a Vermont form and can be used in Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Department of Labor Workers' Compensation Division 5 Green Mountain Drive, PO Box 488 Montpelier, VT 05601-0488 (802) 828-2286 DOL FORM 2 Rev. 9/11 State File No. Date of Injury Ins. Co. File No. Denial of Workers' Compensation Benefits by Employer or Carrier Your employer has filed this denial in accordance with Vermont Workers' Compensation Rule 3.0900. Notice must be sent to the injured worker and the Department of Labor. Supporting evidence must be attached. TO: Claimant's Name: Address: Employer: Date Notice of Injury Received by Employer: Body Part Injured/Injuries Reported to Carrier: Entire Claim Denied Indemnity Benefits Denied Medical Benefits Denied Telephone No.: Date of Injury: Specify grounds for denial and give a brief statement of the specific facts supporting the grounds for denial. DOCUMENTS ATTACHED A. B. C. D. E. F. G. H. Issued By: Carrier: Adjuster Name: Adjuster Signature: Date Notice Sent to Claimant: PAGE 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Medical Bill not Related to Accepted Injury. No Injury Arising Out of and in the Course of Employment. No Indemnity Due. No Causal Relationship Between Injury and Disability. Medical Release (Form 7) Not Returned by Claimant. Treatment is Not Reasonable, Necessary or Related to the Injury Preauthorization of Medical Treatment Other (Specify): Administrator (if not carrier): Telephone No. Employer DOL Form 2 Page 2 of 2 State File Number: NOTICE and FORM for EMPLOYEE to APPEAL DENIAL TO APPEAL, COMPLETE THE INFORMATION BELOW AND ATTACH EVIDENCE (for example, doctor's notes, emergency room records, any other medical records such as physical therapy, radiology reports, etc. or witness statements) TO SUPPORT YOUR INJURY AROSE OUT OF YOUR WORK. KEEP A COPY OF THE FORM FOR YOUR RECORDS AND MAIL A COPY OF THIS FORM TO The Department of Labor at the address above and the Insurance Carrier. Did you notify your employer/supervisor of the injury/illness? Yes Briefly explain how the injury/illness occurred (attach additional pages if necessary): Did you lose time from work because of the injury? If yes, on what date did you begin losing time from work? If you have returned to work, indicate the date on which you returned. Yes No No Pleases check off and attach documents that you are relying on for your appeal: treatment notes from each office visit you had with nay medical provider emergency room records radiology reports (not films) chiropractic records physical therapy notes written clarification from your treating providers as to whether they feel your condition is work-related (strongly recommended). I am seeking all workers' compensation benefits allowed by law. Employee Signature If you have further questions please call or office at (802) 828-2286 or check our web-site at www.labor.vermont.gov Date Signed Equal Opportunity is the Law. The State of Vermont is an Equal Opportunity/Affirmative Action Employer. Applications from women, individuals with disabilities, and people from diverse cultural backgrounds are encouraged. Auxiliary aids and services are available upon request to individuals with disabilities. 711(TTY/Relay Service) or 802-828-4203 TDD (Vermont Department of Labor). American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
