Fill and Sign the Contact Workers Compensationdepartment of Labor Form

Department of Labor DOL Form 27 Rev. 5/16 Workers’ Compensation Division State File No.: 5 Green Mountain Drive, PO Box 488 Ins. Co. File No.: Montpelier, VT 05601-0488 Date of Injury: (802) 828-2286 www.labor.vermont.gov EMPLOYER’S NOTICE OF INTENTION TO DISCONTINUE PAYMENTS TO THE INSURANCE ADJUSTER: Please review the accompanying instructions carefully. If you fail either to submit required documentation and/or to provide proper notice, the discontinuance will be rejected. Employee Name: Employer: Employee Address: Employee’s Attorney (if represented): Employee has been out of work: days TO THE INJURED WORKER: Your workers’ compensation benefits are about to be discontinued. Effective you will stop receiving the following benefits: Temporary Total Disability Temporary Partial Disability Specific medical treatment as follows: Your weekly wage replacement benefits are stopping because: According to the attached medical report, dated you have reached an end medical result for your work injury. You have failed to accept a suitable offer to return to work. You have failed to conduct a good faith search for suitable work. You have failed to attend a scheduled independent medical examination. Other: Your medical benefits are stopping because: According to the attached medical report, dated , the medical treatment specified above: is not medically necessary and/or is not causally related to your work injury. Other: You have the right to object to this discontinuance. If you wish to do so, you must notify the Workers’ Compensation Division, in writing, at the above address. List the reason(s) why you believe the discontinuance should be rejected, and attach all supporting medical records and/or other documentation. To ensure proper processing, please include your state file number as well. Insurance Adjuster Insurance Carrier Name Insurance Carrier Address Insurance Adjuster Phone Number Insurance Adjuster Signature Date Notice Mailed Date Reviewed Commissioner or Designee Signature NOTICE OF POTENTIAL ELIGIBILITY FOR UNEMPLOYMENT INSURANCE BENEFITS If the insurance company is proposing to discontinue your TTD benefits you may be eligible for unemployment insurance benefits, provided that you have a work capacity and are able and available for work. To explore your potential eligibility, you must contact the Unemployment Initial Claims Line at 1-877-214-3330 within 6 months from the date when your benefits ended. [21 VSA §1343(d)]. You can find more information about unemployment benefits on-line at www.labor.vermont.gov under the “Workers - Unemployed” section. If you are found eligible, you will only be paid for weeks claimed in a timely manner, and made with certification of where you have searched for work you are qualified and able to perform. INSTRUCTIONS FOR COMPLETING THE NOTICE OF INTENTION TO DISCONTINUE PAYMENTS (FORM 27) To the insurance adjuster: Please review these instructions carefully. IF YOU FAIL EITHER TO SUBMIT REQUIRED DOCUMENTATION AND/OR TO PROVIDE PROPER NOTICE, THE DISCONTINUANCE WILL BE REJECTED. 1. The Form 27 must be received by the claimant, his or her attorney if represented, and the Department at least 7 days prior to its EFFECTIVE DATE. 21 V.S.A. §643a. Assuming 3 days’ mailing time, in most cases this means that the notice must be mailed AT LEAST 10 DAYS prior to its EFFECTIVE DATE. 2. You must include with the Form 27 ALL RELEVANT EVIDENCE not already submitted to the claimant, his or her attorney if represented, and the Department. This includes evidence that supports the proposed discontinuance as well as evidence that supports continuing benefits. 21 V.S.A. §643a. 3. For discontinuances based on end medical result, please refer to Workers’ Compensation Rule 12.1200. You MUST ATTACH medical report(s) documenting that the claimant has reached an end medical result. “End medical result” is defined as “the point at which a person has reached a substantial plateau in the medical recovery process, such that significant further improvement is not expected, regardless of treatment.” The fact that a claimant has reached an end medical result IS NOT an appropriate basis for discontinuing medical or vocational rehabilitation benefits. 4. For discontinuances based on the claimant’s failure either to accept a suitable offer to return to work or to conduct a good faith search for suitable work, please refer to Workers’ Compensation Rule 12.1300. You MUST ATTACH written documentation of the following: (a) That the claimant has been medically released to return to work, either with or without restrictions; AND (b) That the claimant has been notified both of the fact of his or her release AND his or her obligation to conduct a good faith search for suitable work; AND (c) That the claimant has either failed to conduct a good faith search for suitable work and/or has refused a written offer of suitable work once notified. Medical benefits CANNOT be discontinued based solely on the above criteria. 5. For discontinuances based on a claimant’s failure to attend a scheduled independent medical exam, you MUST ATTACH a copy of the scheduling notice sent to the claimant as well as written notice from the examiner documenting that the claimant failed to attend. 6. If the claimant has been out of work for at least 90 days, you MUST ATTACH written verification that he or she has been offered vocational rehabilitation screening and/or services. 21 V.S.A. §§641 and 643a.