Fill and Sign the Dol Form 16 Rev

Workers’ Compensation Division DOL Form 16 (Rev. 7/14) 5 Green Mountain Drive, PO Box 488 State File No.: Montpelier, VT 05601-0488 Ins. Co. File No.: Date of Injury: COMPROMISE AGREEMENT Claimant, , whose address is and employer/insurance carrier, , hereby agree to a compromise settlement of Claimant’s claim for workers’ compensation benefits arising out of an alleged work-related accident on while he or she was employed by and in which he or she allegedly suffered the following injury: . Claimant’s average weekly wage before the accident was: $ . This is an agreement in which Claimant agrees to accept $ in full and final settlement of the following benefits: Any and all workers’ compensation benefits causally related to the above referenced injury Temporary Total Disability Permanent Partial Disability Permanent Total Disability Temporary Partial Disability Vocational Rehabilitation Medical Other (attach additional sheet if necessary): It is agreed that the employer/insurance carrier will continue to furnish all workers’ compensation benefits causally related to the alleged injury referenced above other than those specifically resolved by this Compromise Agreement. IF payment is to be in a lump sum: Claimant agrees to accept and the employer/insurance carrier agrees to pay a lump sum of $ . This lump sum is compensation for permanent impairment that will affect Claimant for the rest of his or her life. Claimant’s remaining life expectancy is years or months. Therefore, even though paid in a lump sum, Claimant’s benefits (after deducting attorney fees of and expenses of ) shall be considered to be $ per month beginning on the date when this Compromise Agreement is approved. OR Claimant agrees to accept and the employer/insurance 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 Compromise Agreement shall not be binding or operative until it is approved by the Commissioner of Labor or designee. Dated at this day of ,20 Employee Insurance Carrier or Employer By: Official Title APPROVED: , 20 Commissioner of Labor/Designee