DOL FORM 28 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 AFTER 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 $1,281 or less than the minimum of $427. (see REMINDER below) ANY CLAIM WHERE THE EMPLOYEE RECEIVED THE MAXIMUM ON JUNE 30, 2017, THE NEW MAXIMUM SHALL BE ENTERED HERE SUBJECT TO EMPLOYEE'S AVERAGE WEEKLY WAGE. $ 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. $ REMINDER: 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 $1,281 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 please provide a copy to the claimant. American LegalNet, Inc. www.FormsWorkFlow.com