Department of Labor Workers’ Compensation Division 5 Green Mountain Drive, PO Box 488 Montpelier, VT 05601-0488 DOL Form 15 State File # Ins. Co. File # Date of Injury Fed ID No. (Rev. 7/10) SETTLEMENT AGREEMENT It is hereby agreed by and between the injured worker, whose address is , and **insurance carrier **employer, that worker claims a work injury on ,20 by the said worker while in the employ of whose address is causing the following injury: and resulting in temporary total disability which began That the employee’s average weekly wage before the accident was , 20 . $ This is an agreement in which the claimant agrees to accept $ , in full and final settlement of all claims for: (describe injury) sustained as a result of the accident referred to above, including **his **her claim for past, present and future compensation for temporary total disability, temporary partial disability, permanent partial disability or permanent total disability, dependency benefits, medical, hospital, surgical and nursing expenses, and vocational rehabilitation benefits. If payment is to be in a lump sum please complete one of the paragraphs below: Claimant agrees to accept and the employer/carrier agrees to pay a lump sum of $ . This lump sum is Compensation for permanent impairment that will affect the claimant for the rest of his/her life. The claimant’s remaining life expectancy is years or months. Therefore, even though paid in a lump sum, claimant’s benefit (after deduction of attorney fees of and expenses of ) shall be considered to be /months $ per month beginning on the date of approval of this settlement OR Claimant agrees to accept and the employer/carrier agrees to pay a lump sum of $ . Claimant expressly Requests that the lump sum not be prorated as otherwise required by 21 VSA §652(c). APPROVAL AND REVIEW This agreement or any settlement thereunder shall not be binding or operative unless and until this settlement agreement is approved by the Commissioner of Labor. Dated at this APPROVED: day of ,20 ,20 Insurance Carrier or Employer Commissioner of Labor/Designee By Official Title Employee Witness **Strike out inappropriate expressions American LegalNet, Inc. www.FormsWorkFlow.com