Vermont > Workers Compensation
Employers Notice Of Intention To Discontinue Payments 27 - Vermont
| Employers Notice Of Intention To Discontinue Payments 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 www.labor.vermont.gov DOL Form 27 State File No.: Ins. Co. File No.: Date of Injury: Rev. 6/10 EMPLOYER'S NOTICE OF INTENTION TO DISCONTINUE PAYMENTS THIS FORM MUST INCLUDE ALL RELEVANT EVIDENCE* TO THE CLAIM AND MUST BE RECEIVED BY THE CLAIMANT, AND THEIR ATTORNEY IF REPRESENTED, AND THE DIVISION OF WORKERS' COMPENSATION AT LEAST 7 DAYS PRIOR TO THE EFFECTIVE DATE pursuant to 21 V.S.A. §643a. Employee Name: Employee Address: Employee's Attorney (if represented): Employer: This employee has been out of work days. The insurer verifies that if the employee has been out of work for 90 days the employee has been offered vocational rehabilitation screening and/or services (21 V.S.A. §643a and 641). Copy of the offer and any screening is attached. Effective the following benefits will be DISCONTINUED for the reasons checked below: Temporary Partial Disability Vocational Rehabilitation Temporary Total Disability Medical Benefits (MUST identify the specific treatment below): TREATMENT being Discontinued: Attach additional pages if necessary Claimant has reached medical end result. Medical report of attached. "End Medical Result" or "Medical End Result" is defined under Rule 2.1200 as "the point at which a person has reached a substantial plateau in the medical recovery process, such that significant further improvement is not expected, regardless of treatment." Medical End Result is basis for stopping Temporary Total or Temporary Partial Disability compensation regardless of work status. IT IS NOT a basis for stopping medical benefits or vocational rehabilitation benefits. Claimant has been released to return to work but has failed to accept a suitable offer of employment or has failed to provide evidence of verifiable, good faith job search information. ALL of the following evidence must be provided pursuant to Rule 18.1300: 18.1310 That the claimant has been medically released to work, either with or without restrictions; AND 18.1320 That the claimant has been notified both of the fact of his or her release and his or her obligation to conduct a good faith job search for suitable work; AND 18.1330 That the claimant has either failed to conduct a good faith search for suitable work and/or has refused an offer of suitable work once notified. MEDICAL BENEFITS CAN NOT BE DISCONTINUED BASED ON RULE 18.1300 CRITERIA. American LegalNet, Inc. www.FormsWorkFlow.com DOL Form 27 Page 2 State File Number: Claimant has failed to attend a scheduled Independent Medical Exam (IME). Evidence must include copy of the scheduling notice sent to claimant and written evidence from the examiner that claimant failed to attend. Pursuant to 21 V.S.A. §655 "If an employee refuses to submit himself to or in any way obstructs such examination, his right to take or prosecute any proceeding under the provisions of this chapter shall be suspended until such refusal or obstruction ceases, and compensation shall not be payable for the period during which such refusal or obstruction continues." Other: Explain reason and identify evidence relied on. Evidence relied on: Attach additional sheets if necessary. *Please note: The insurer/employer is required to submit all relevant evidence in its possession, including evidence that does not support its position, with the discontinuance unless that evidence already has been submitted to the Division of Workers' Compensation and the employee/employee's attorney (21 V.S.A. §643a). Insurance Carrier Date Notice Mailed Insurance Adjuster (Print Name) Date Reviewed Insurance Carrier Address Commissioner or Designee Signature Insurance Carrier Phone Number Insurance Adjuster Signature Insurance Carrier's Attorney (if represented) NOTICE TO EMPLOYEE'S OF RIGHT TO APPEAL IF YOU DISAGREE WITH THE NOTICE TO DISCONTINUE BENEFITS, you may request a hearing IN WRITING to the Division of Workers' Compensation at the address above. ATTACH medical documentation and any other information to support your appeal. PLEASE BE SURE TO PUT YOUR STATE FILE NUMBER ON YOUR HEARING REQUEST. American LegalNet, Inc. www.FormsWorkFlow.com
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