DOL Form 23 (Rev. 6/10) www.labor.vermont.gov Department of Labor Workers' Compensation Division PO Box 488 Montpelier, VT 05601-0488 (802) 828-2286 AGREEMENT FOR COMPENSATION IN FATAL CASES State File No. Ins. Co. File No. Date of Injury Fed. ID No. IT IS AGREED, between of the dependents of the deceased employee of , *spouse, *reciprocal beneficiary, *dependent, *guardian Employer Employer's Address: Street, City, State, Zip and By reason of the fatal accident injury suffered on , 20 of the city/town of in the County of causing the following injury from which death resulted on , 20 and State of , the insurance carrier/employer , by the said employee while in the employ of BURIAL EXPENSE It is agreed that the deceased employee's burial expense shall be borne by the *insurance carrier/*employer in accordance with the provision of 21 VSA §632. DEPENDENTS It is agreed that the following persons were dependent upon the deceased employee for support and by reason of his/her death are entitled to compensation as provided by law: Name Relationship Date of Birth WEEKLY COMPENSATION It is agreed that the employee's average weekly wage for the twenty-six weeks before the injury was Dependents are entitled to beginning % (percent) of said average weekly wage, the sum of , 20 $ $ and that said and continuing until a change in the condition of dependency occurs, after which the amount due weekly shall be redetermined. The period of payment shall not exceed the limits set forth in 21 VSA§635, as amended. Day of the week the check will be mailed to the dependent or deposited in the dependent's account APPROVAL AND REVIEW This agreement or any settlement thereunder shall not be binding or operative unless and until this agreement and such settlement is approved by the Commissioner of Labor. Insurance Adjuster Name (Print) Spouse, Reciprocal Beneficiary, Dependent or Guardian of Dependents (Print) Insurance Adjuster Signature Spouse, Reciprocal beneficiary, Dependent or Guardian of Dependents Signature Official Title Date Date APPROVED: *Strike out inappropriate expressions. ,20 Commissioner of Labor/Designee American LegalNet, Inc. www.FormsWorkFlow.com