Fill and Sign the Vermont Workers Compensation Form

DOL FORM 15 (Rev. 5/05) State File No.       Ins. Co. File No.       Date of Injury       Fed. ID No.       DEPARTMENT OF LABOR WORKER’S COMPENSATION DIVISION SETTLEMENT AGREEMENT It is hereby agreed by and between       the employee of the town of       and the state of       , and       **insurance carrier ** employer , by reason of an accidental injury suffered at       on       , 20       by the said employee while in the employ of             in the town of       and the state of       causing the following injury:       and resulting temporary total disability which began       , 20       . That the employee’s average weekly wage for twelve weeks before the accident was $       This is an agreement in which the claimant agrees to accept $       , in full and final settlement of all claims for injuries sustained as a result of the accident referred to above, including **his **her Claim for past, present and future compensation for temporary total disability, temporary partial disability, permanent partial disability or permanent total disability, dependency benefits, medical, hospital, surgical and nursing expenses, and vocational rehabilitation benefits. APPROVAL AND REVIEW This agreement or any settlement thereunder shall not be binding or operative unless and until this settlement agreement is approved by the Commissioner of Labor. Dated at this       day of       , 20       APPROVED:       , 20       Insurance Carrier or Employer By Commissioner of Labor/Designee       Official Title       Employee **Strike out inappropriate expressions. Witness