Fill and Sign the Department of Labor Workers Compensation Division Po Box 488 Form

Vermont Department of Labor Form 10 (rev 9/11) Workers’ Compensation State File # PO Box 488 Ins. Co. File # Montpelier, VT 05601-0488 Date of Injury (802) 828-2286 www.labor.vermont.gov Certificate of Dependency and Concurrent Employment Employee: Employer: TO THE EMPLOYEE: This form MUST be comp leted in every workers’ compensation case in which an injured worker has lost time from work as the result of a work -related injury. The form must be completed even when the injured worker has no dependents . The information must be supplied and the form signed by the injured worker. This information is required to determine the employ ee’s right to additional weekly compensation of $10.00 for each dependent child under the age of twe nty-one (21) years. List below your dependent child(ren) up to 21 years old that have not already been declared by your spouse on his/her current workers’ compensation claim.** Name of Dependent Date of Birth Relationship Concurrent employment: If you were working for more than one employer on the date of injury indicated above please provide th e following information.** Name of Employer Employer’s Address Em ployer’s Phone Number Date of Hire I hereby certify that the above is a true, complete and accurate statement of my dependent s and concurrent employment. Employee Signature Date Signed Address Telephone Number City/State/Zip **Attach additional sheets if necessary and return this to the insurance carrier