Fill and Sign the Dol Form 25 Rev 913 State of Vermont Department

DOL Form 23 (Rev. 6/10) Department of Labor State File No. Workers’ Compensation Division Ins. Co. File No. PO Box 488 Date of Injury Montpelier, VT 05601-0488 Fed. ID No. www.labor.vermont.gov (802) 828-2286 AGREEMENT FOR COMPENSATION IN FATAL CASES IT IS AGREED, between , *spouse, *reciprocal beneficiary, *dependent, *guardian of the dependents of the deceased employee of Employer Employer’s Address: Street, City, State, Zip and , the insurance carrier/employer By reason of the fatal accident injury suffered on , 20 , by the said employee while in the employ of of the city/town of in the County of and State of causing the following injury from which death resulted on , 20 BURIAL EXPENSE It is agreed that the deceased employee’s burial expense shall be borne by the *insurance carrier/*employer in accordance with the provision of 21 VSA §632. DEPENDENTS It is agreed that the following persons were dependent upon th e deceased employee for support and by reason of his/her death ar e entitled to compensation as provided by law: Name Relationship Date of Birth WEEKLY COMPENSATION It is agreed that the employee’s average weekly wage for the tw enty-six weeks before the injury was $ and that said Dependents are entitled to % (percent) of said average weekly wage, the sum of $ beginning , 20 and continuing until a change in the condition of dependency occurs, after which the amount due weekly shall be redetermined. The period of payment shall not exceed the limits set forth in 21 VSA§635, as amended. Day of the week the check will be mailed to the depende nt or deposited in the dependent’s account APPROVAL AND REVIEW This agreement or any settlement thereunde r shall not be binding or operative unless and until this agreement and such settleme nt is approved by the Commissioner of Labor. Insurance Adjuster Name (Print) Spouse, Reciprocal Beneficiary, Dependent or Guardian of Dependents (Print) Insurance Adjuster Signature Spouse, Reciprocal beneficiary, Dependent or Guardian of Dependents Signature Official Title Date Date APPROVED: ,20 Commissioner of Labor/Designee *Strike out inappropriate expressions.