DOL FORM 28A FY-18 Rev 6/17 State File No. Workers222 Compensation Division Ins. Co. File No. PO Box 488, Montpelier, VT 05601-0488 Date of Injury www.labor.vermont.gov Fed. ID No. NOTICE OF CHANGE IN COMPENSATION RATE (for INJURIES BEFORE JULY 1, 1986) RE: v. (Employee) (Employer) Check type of agreement involved: Temporary Total Permanent Total Fatal Temporary Partial Permanent Partial 1. Write in the employee222s compensation rate effective June 30, 2017. (Not including dependent222s benefits.) $ 2. Multiply line 1 by 1.018 and write in the result, but not more than the maximum rate of $854 or less than the Minimum of $427. $ 3. For Temporary Total Disability cases ONLY, multiply the number of dependents under the age of 21 by $10 and write in the result. $ 4. Write in the TOTAL of lines 2 and 3. This is the new compensation rate for the year beginning July 1, 2017. $ Maximum rate is $854 and the minimum rate is $427 (not including dependent222s benefits) for the year beginning July 1, 2017. 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 Adjuster222s 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, 2017. File with the Department of Labor before July 15, 2017. After the change has been approved, provide a copy to the claimant. American LegalNet, Inc. www.FormsWorkFlow.com