Fill and Sign the Vermont Partial Form

DOL FORM 24 (Rev. 5/05) State File No.       Ins. Co. File No.       Date of Injury       Fed. ID No.       DEPARTMENT OF LABOR WORKERS’ COMPENSATION DIVISION AGREEMENT FOR TEMPORARY PARTIAL DISABILITY COMPENSATION IT IS AGREED, between       , the employee, whose mailing address is:       Street, Rural Route, Box Number, City, State, Zip AND       the insurance carrier/employer, that on       , 20       the employee suffered an accident while in the employ of       of the city/town of       state of       causing the following injury:             and resulting in temporary total disability beginning on       , 20       . WEEKLY COMPENSATION RATE The employee’s average weekly for the twelve weeks before the accident was $       and that he/she has weekly earnings of $       and he/she is entitled to temporary partial compensation of $       per week. **Maximum and minimum weekly compensation rates are set annually by a self-adjusting formula. New rates are effective July 1 of each year and apply to accidents which occur between that date and July 1 of the following year. New rates are adopted and published annually by the Commissioner of Labor during the month of May. MEDICAL, HOSPITAL AND SURGICAL SERVICES That the employee shall receive medical, hospital, surgical and nursing services and supplies in accordance with the provision of 21 V.S.A. § 640. The expense of such services and supplies shall be borne by the insurance carrier/employer. TEMPORARY PARTIAL DISABILITY Beginning the 8 th day of temporary partial disability or at the end of temporary total disability, on the       day of       , 20       the employee shall receive compensation at said temporary partial rate. APPROVAL AND REVIEW This agreement or any settlement thereunder shall not be binding or operative unless and until this agreement and such settlement is approved by the Commissioner of Labor, and is subject to review by said Commissioner upon their own motion or on motion of either party upon the ground of a change in physical condition of the employee entitled to compensation hereunder. Insurance Adjuster Signature Employee Signature Date Official Title Date Social Security Number APPROVED: Date Commissioner of Labor/Designee