Fiscal Year 2009 Notice Of Change In Compensation Rate (For Injuries Before)
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Fiscal Year 2009 Notice Of Change In Compensation Rate (For Injuries Before) Form. This is a Vermont form and can be use in Workers Compensation.
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Tags: Fiscal Year 2009 Notice Of Change In Compensation Rate (For Injuries Before), 28A, Vermont Workers Compensation,
DOL FORM 28A
FY-09 Rev 5/08
State File No.
Ins. Co. File No.
STATE OF VERMONT
DEPARTMENT OF LABOR
Date of Injury
WORKERS’ COMPENSATION DIVISION
Fed. ID No.
Social Sec. No.
www.state.vt.us/labind
NOTICE OF CHANGE IN COMPENSATION RATE
(for INJURIES BEFORE JULY 1, 1986)
RE:
v.
(Employee)
Check type of agreement involved:
(Employer)
Permanent Total
Temporary Partial
1.
Temporary Total
Fatal
Permanent Partial
Write in the employee’s compensation rate effective June 30, 2008.
(Not including dependent’s benefits.)
2.
$
Multiply line 1 by 1.040 and write in the result, but not more than the maximum rate of $702 or less than the
Minimum of $351.
3.
4.
$
For Temporary Total Disability cases ONLY, multiply the number of dependents under the age of 21 by $10 and
write in the result.
$
Write in the TOTAL of lines 2 and 3. This is the new compensation rate for the year beginning July 1, 2008.
$
Maximum rate is $702 and the minimum rate is $351 (not including dependent’s benefits) for the year beginning July 1, 2008.
This is an amendment to the original Temporary Total, Temporary Partial, Permanent Partial, Permanent Total, or Fatal agreement.
Insurance Company or Self-Insured
Date
Claims Adjuster’s Signature
Title
Commissioner of Labor & Industry/Designee
Date
Instructions to insurance company or self-insurer: Complete above. Increase the weekly compensation rate beginning July 1, 2008. File three (3) copies with the
Department of Labor before July 15, 2008. After the change has been approved, provide copies 2 and 3 to the carrier and the claimant.
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