Denial Of Workers Compensation Benefits By Employer Or Carrier {2}

Department of Labor DOL FORM 2 Rev. 4/2018 Workers222 Compensation Division 5 Green Mountain Drive, PO Box 488 State File No. Montpelier, VT 05601 - 0488 Date of Injury (802) 828 - 2286 ; TDD 800 - 650 - 4152 Ins. C o. File No. D enial of Workers222 Compensation B enefits by Employer or Carrier THIS FORM IS FILED BY YOUR EMPLOYER222S WORKERS222 COMPENSATION INSURANCE COMPANY. They have filed this denial in accordance with Vermont Workers222 Compensation Rule 3.2200. Notice must be sent to the injured worker and the Department of Labor. Supporting evidence must be attached. TO: Claimant222s Name: Address: Telephone No.: Emplo yer: Date of Injury : Date Notice of Injury Received by Employer: Bod y part injured/injuries accepted by c arrier : Entire Claim Denied Indemnity Benefits Denied Medical Benefits Denied Check off only the reasons below that apply and give a brief statement of the specific facts you are relying on to support the denial. DOCUMENTS ATT ACHED A. Medical b ill not r elated to a ccepted i njury (please specify date of bill) . B. No injury arising out of and in the course of e mployment. C. No indemnity d ue . D. No causal r elat ionship b etween injury and d isability. E. Medical r elease ( Form 7 ) not returned by c laimant . F. Tre atment is not reasonable, necessary or related to the i njury G. Preauthorization of medical t reatment H . Other (Specify) : Issued By: Carrier: Administrator (if not carrier): Adjuster Name: Telephone No. : Adjuster Signature: Employer : Date Notice Sent to Claimant: PAGE 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 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, doctor222s notes, emergency room records, any other medical records such as physical therapy, radiology reports, etc. or witness statements) TO SUPPORT THAT YOUR INJURY AROSE OUT OF YOUR WORK. KEEP A COPY OF THIS FORM FOR YOUR RECORDS AND MAIL A COPY OF IT TO BOTH the Department of Labor at the address above and the insurance carrier. Did you notify your employer/supervisor of the injury/illness? Yes No Identify who you reported the injury to and on what date. Briefly e xplain how the injury/illness occurred (attach additional pages if necessary) : Did you lose time from work because of the injury? Yes No If yes, on what date did you begin losing time from work? If you have returned to work, indicate the date on w hich you returned. Please check off and attach documents that you are relying on for your appeal: treatment notes from each office visit you had with any 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 workers222 compensation benefits allowed by law. Employee Signature Date Signed Employee Printed Name Employee Current Mailing Address Employee E - mail Address Employee Current City, State, Zip Employee Conta ct Phone Number If you have further questions please call or office at (802) 828-2286 or check our website at www.labor.vermont.gov American LegalNet, Inc. www.FormsWorkFlow.com