Department of Labor Workers’ Compensation Division 5 Green Mountain Drive, PO Box 488 Montpelier, VT 05601-0488 (802) 828-2286 DOL Form 24 State File No.: Ins. Co. File No.: Date of Injury: Rev. 6/10 Agreement for Temporary Partial Disability Compensation IT IS AGREED, between , the employee, whose mailing address is: Street, Rural Route, Box Number, City, State, Zip AND the insurance carrier/employer, that on suffered an accident while in the employ of state of ,20 the employee of the city/town of causing the following injury: and resulting in temporary total disability beginning on ,20 WEEKLY COMPENSATION RATE The employee’s average weekly wage for the twelve/twenty-six weeks before the accident was that he/she has weekly earnings of $ $ $ and and he/she is entitled to temporary partial compensation of per week. Day of the week the check will be mailed to the claimant or deposited in the claimant’s account: **Maximum and minimum weekly compensation rates are set annually by a self-adjusting formula. New rates are effective July 1 of each year and apply to accidents which occur between that date and July 1 of the following year. New rates are adopted and published annually by the Commissioner of Labor during the month of June. MEDICAL, HOSPITAL AND SURGICAL SERVICES That the employee shall receive medical, hospital, surgical and nursing services and supplies in accordance with the provision of 21 V.S. A. § 640. The expense of such services and supplies shall be borne by the insurance carrier/employer. TEMPORARY PARTIAL DISABILITY Beginning the 8th day of temporary partial disability or at the end of temporary total disability, on the ,20 day of the employee shall receive compensation at said temporary partial rate. APPROVAL AND REVIEW This agreement or any settlement there under shall not be binding or operative unless and until this agreement and such settlement is approved by the Commissioner of Labor, and is subject to review by said Commissioner upon their own motion or on motion of either party upon the ground of a change in physical condition of the employee entitled to compensation hereunder. Insurance Adjuster Signature Date Printed Name Employee Signature Date Official Title APPROVED: Date Commissioner of Labor/Designee American LegalNet, Inc. www.FormsWorkFlow.com