Agreement For Temporary Total Disability Compensation
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Agreement For Temporary Total Disability Compensation Form. This is a Vermont form and can be use in Workers Compensation.
Tags: Agreement For Temporary Total Disability Compensation, 21, Vermont Workers Compensation,
Department of Labor
Workers’ Compensation Division
5 Green Mountain Drive, PO Box 488
Montpelier, VT 05601-0488
(802) 828-2286
DOL Form 21
Rev 6/10
State File No.:
Ins. Co. File No.:
Date of Injury;
Agreement for Temporary Total Disability Compensation
IT IS AGREED, between
, the employee, whose present mailing address is:
Street, Rural Route, Box Number, City, State, Zip
AND
, the insurance carrier/employer that on
an accident while in the employ of
state of
the employee suffered
of the city/town of
causing the following injury:
and resulting in temporary total disability beginning on:
WEEKLY COMPENSATON RATE
The employee is entitled to a weekly compensation rate of two-thirds (66.667%) of his/her average weekly wage not to exceed his/her
weekly net income. S/he is further entitled to an additional $10.00 per week for each dependent child under 21 years of age provided
that the total weekly compensation not exceed the employee’s weekly net income.
A.
B.
C.
D.
Claimant’s Average Weekly Wage
Weekly Compensation Rate
(66.667% of A.W.W.; Weekly Net Income; Minimum or Maximum Rate)
Number of Dependents multiplied by $10.00
Total Weekly Compensation Rate
A.
B.
$
$
C.
D.
$
$
DISABILITY
Beginning on the fourth day of disability, the
the employee shall receive compensation at said rate.
day of
and continuing during the period of total disability,
Day of the week the check will be mailed to the claimant or deposited in the claimant’s account
EMPLOYEE OBLIGATION TO REPORT WORK AND EARNINGS
Temporary Total Disability compensation is provided only where an injury causes total disability from any work. By signing this
agreement the employee is stating that he or she is not currently working, and that he or she is obligated to report promptly any work
earnings, wages or benefits to the insurance carrier/employer and the department.
Insurance Adjuster Name (Print)
Insurance Adjuster Signature
Employee Name (Print)
Date
Employee Signature
Date
APPROVED:
Date
Commissioner of Labor/Designee
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