Fill and Sign the Fillable Online Form 25 Vermont Department of Labor Vermont

De partment of Labor, Workers’ DOL FORM 25 (Rev. 1/2018 ) Workers’ Compensation PO Box 488 State File No. Mont pelier, VT 05601-0488 Ins. Co. File No. (802 ) 828-2286; TDD 800-650-4152 Date of In jury www.labor.vermont.gov Fed. ID No. WAGE STATEMENT –For in juries occurrin g on or after Jul y 1, 2008 Employee: Em ployer: Wage Rate: $ per Number of Days Hired to Work: Number of Hours Hired to Work: Week Ending Number of Hours or Days Worke d Gross Wages Extras (as in 6 or 7) Please indicate what the extra is, for example, $1000.00 bonus INSTRUCTIONS: Read Carefully 1. Enter GROSS wages of employee for 26 weeks before date of accident (NOT take-home pay). 2. Do not include the week of the accident. 3. Leave blank those weeks in which the employee had excused absences for which he/she was paid for less than ½ of a work week. 4. Leave blank those weeks in which you had reduced operations or a plant shutdown and for which the employee was paid for less than ½ of a work week. 5. Do not enter those weeks in which an employee was on vacation for more than ½ of a work week. 6. If room, board, lodging or other “extras” (electricity, fuel, etc.) are provided in addition to monetary wages, break these down into a weekly value, and include and describe the income in the column marked “EXTRAS.” This includes tips if not included in gross wages. 7. Include any bonuses and commissions paid to the employee in addition to wages in the column marked “EXTRAS.” 8. Enter the dates when your normal work week ends (not the date a check is issued to the employee) and the number of hours or days worked. Month Day Year 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 When did the employee begin losing time? Was the employee paid in full for the day of the accident? Are em ployee’s wa ges sub ject to an y child su pport withholdin g order? Yes No If yes, in what amount? $ per Da y of the week the check will be mailed to the claimant or de posited in the claimant’s account This is a correct statement of the em ployee’s earnin gs as taken from the em ployer’s payroll records. B y: Position Title: Signature of Prepare r Print Name: Date: