Fiscal Year 2011 Notice Of Change In Compensation Rate (For Injuries After)
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Fiscal Year 2011 Notice Of Change In Compensation Rate (For Injuries After) Form. This is a Vermont form and can be use in Workers Compensation.
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Tags: Fiscal Year 2011 Notice Of Change In Compensation Rate (For Injuries After), 28, Vermont Workers Compensation,
FY-11 Rev 6/10
DOL FORM 28
State File No.
Ins. Co. File No.
STATE OF VERMONT
DEPARTMENT OF LABOR
WORKERS’ COMPENSATION DIVISION
www.labor.vermont.gov
Date of Injury
Fed. ID No.
PO Box 488, Montpelier, VT 05601-0488
NOTICE OF CHANGE IN COMPENSATION RATE
(for INJURIES AFTER 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, 2010.
(Not including dependent’s benefits.)
2.
$
Multiply line 1 by 1.012 and write in the result, but not more than the maximum rate of $1,119 or less than
the minimum of $373. (see REMINDER below)
ANY CLAIM WHERE THE EMPLOYEE RECEIVED THE MAXIMUM ON JUNE 30, 2010, THE NEW
MAXIMUM SHALL BE ENTERED HERE SUBJECT TO EMPLOYEE'S AVERAGE WEEKLY WAGE.
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, 2010.
$
REMINDERS:
FOR INJURIES BETWEEN JULY 1, 1994 AND MAY 25, 2004 THE COMPENSATION RATE
CANNOT EXCEED THE WEEKLY NET INCOME. FOR INJURIES AFTER MAY 25, 2004 THE
COMPENSATION RATE CANNOT EXCEED 90% OF THE AVERAGE WEEKLY WAGE
TEMPORARY TOTAL OR TEMPORARY PARTIAL COMPENSATION SHALL FIRST BE
ADJUSTED ON THE FIRST JULY 1 FOLLOWING THE RECEIPT OF 26 WEEKS OF BENEFITS.
Maximum rate is $1,119 and the minimum rate is $373 (not including dependent’s benefits) for the year beginning July 1, 2010.
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, 2010. File three (3) copies with the
Department of Labor before July 15, 2010. After the change has been approved, provide copies 2 and 3 to the carrier and the claimant.
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