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Worker Adjustment and Retraining Notification

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AGREEMENT FOR PERMANENT PARTIAL or PERMANENT TOTAL DISABILITY COMPENSATION

DEPARTMENT OF LABOR

WORKERS’ COMPENSATION DIVISION

www.labor.vermont.gov

DOL FORM 22 (Rev. 6/10)

State File No.

Ins. Co. File No.

Date of Injury

IT IS AGREED, between , the employee,

whose address is:

and , the insurance carrier/employer, that the employee suffered an accident while in the employ of

and that the employee sustained the following injury:

which resulted in temporary total disability beginning on , 20 or no lost time.

WEEKLY COMPENSATION RATE

Employee’s average weekly wage (AWW) before the accident was $ S/he is entitled to compensation at the rate of 66 2/3 percent of said AWW or $ per week. This is updated on July 1 of each year and is now $ per week.

A transcript of the employee’s wages for the twelve/twenty-six weeks was previously submitted or is attached.

Day of the week the check will be mailed to the claimant or deposited in the claimant’s account

MEDICAL, HOSPITAL AND SURGICAL SERVICES

That the employee shall receive medical services and supplies in accordance with 21 VSA§640.

PERMANENT PARTIAL or PERMANENT TOTAL DISABILITY

Employee is entitled to:

At the end of temporary total or temporary partial, on the day of 20 the employee having either

or for which a discontinuance, Form 27 was filed on

The impairment rating is . This impairment represents a payment of compensation benefits for a period of weeks.

The impairment rating is based upon the following medical report: Dr.

If payment is to be in a lump sum please complete one of the paragraphs below:

Claimant agrees to accept and the employer/carrier agrees to pay a lump sum of $ This lump sum is compensation for permanent impairment that will affect the claimant for the rest of his/her life. The claimant’s remaining life expectancy is years or months. Therefore, even though paid in a lump sum, claimant’s benefit (after deduction of attorney fees of and expenses of ) shall be considered to be /months $ per month beginning on the date of approval of this settlement

OR

Claimant agrees to accept and the employer/carrier agrees to pay a lump sum of $ . Claimant expressly requests that the lump sum not be prorated as otherwise required by 21 V.S.A. §652(c)

The employee is entitled to seek an opinion on permanent impairment from his/her treating physician

APPROVAL AND REVIEW

This agreement is subject to review by the Commissioner and shall not be binding or operative until approved.

Insurance Adjuster Name (Print)

Employee Signature

Date

Insurance Adjuster Signature

Official Title

Date

APPROVED:

Date

Commissioner of Labor/Designee

Enter text✕

What the Worker Adjustment and Retraining Notification Is

The Worker Adjustment and Retraining Notification (commonly called the WARN notice) is a federal employment law requirement for covered employers to provide advance written notice to affected employees, state dislocated worker unit(s), and local government officials before plant closings or mass layoffs. The federal WARN Act requires a 60-day notice for qualifying events (29 U.S.C. §2102). Many states also have their own 'mini-WARN' laws with different thresholds or notice obligations. This page explains the notice content, timing, common pitfalls, and how to prepare, deliver, and retain WARN notices effectively.

Why a Proper WARN Notice Matters

A compliant WARN notice reduces legal exposure, preserves employee rights to transitional services, and supports orderly workforce transitions. Proper notices help avoid statutory penalties, back pay liabilities, and litigation costs while documenting employer good-faith compliance with federal and state law.

Why a Proper WARN Notice Matters

Who Prepares and Receives WARN Notices

Coordination among these groups ensures notices are accurate, timely, and routed to all statutorily required recipients to limit penalties and operational disruption.

  • Human resources and benefits teams preparing employee notices and documentation.
  • In-house or outside employment counsel advising on legal thresholds and exceptions.
  • State workforce agencies and local government officials who receive official notices.

Step-by-step: Preparing a WARN Notice

Follow these core steps to determine coverage and issue a compliant notice.

  • 01
    Assess Coverage: Determine if employer meets thresholds and the event qualifies under the WARN Act.
  • 02
    Confirm Dates: Set the expected layoff/closure date and calculate the 60-day window.
  • 03
    Draft Notice: Prepare written notice with required content including affected positions and contact information.
  • 04
    Deliver & Document: Serve all statutory recipients and retain proof of delivery and internal approvals.

Configure your digital WARN notice workflow

Use a template-driven workflow to control versions, recipients, and authentication for electronic delivery.

Field Configuration
Template Predefined WARN template with required fields
Recipient list HR roster, state dislocated worker unit, local official emails
Authentication Email link or SMS code for signer verification
Retention Automatically archive signed notice and delivery audit trail

Typical process for issuing and recording a WARN notice

A clear sequence helps ensure deadlines and recipients are met.

  • Prepare draft: Draft notice with required content and internal approvals.
  • Authorize release: Obtain executive and legal sign-off before distribution.
  • Send notice: Deliver to employees, state unit, and local officials; record delivery proof.
  • Archive record: Store signed notice, delivery receipts, and internal approvals for retention period.

Key timing rules and common exceptions

WARN timing is time-sensitive; note statutory deadlines and recognized exceptions when calculating notice.

Standard notice period:

60 days per WARN Act (29 U.S.C. §2102)

Shorter notice allowed:

Exceptions for faltering companies, unforeseeable business circumstances, and natural disasters

State mini-WARNs:

Some states impose additional notice rules with different thresholds

Effective date impact:

Notice date starts the 60-day countdown; accurate dating is critical

Documentation:

Retain proofs of delivery and internal decision records across statutory retention periods

Milestones from decision to archival

A sequential checklist clarifies responsibilities and when each milestone must be completed.

01

Decision point

Management confirms layoff or closure and documents rationale and effective date.

02

Legal review

Employment counsel reviews event, assesses WARN coverage and exceptions.

03

Issue notice

Deliver written notices to employees and required agencies within the 60-day window.

04

Archive and defend

Preserve notice, approvals, delivery receipts, and related records for retention period.

Security and compliance controls for WARN notices

Encryption: TLS 1.2/1.3; AES-256 at rest
Audit trail: Detailed timestamp and IP audit
Authentication: Multi-factor and access controls
HIPAA BAA: Available where PHI applies
Retention: Configurable, immutable archives
Certifications: SOC 2 Type II, ISO 27001

Penalties and legal risks from improper notice

Back pay liability: May include 60 days' pay
Civil penalties: Statutory fines and assessments
Litigation costs: Attorney fees and defense costs
State penalties: Additional state-level sanctions
Reputational risk: Employee and community impact
Recordkeeping failures: Weakened defense in disputes

Common preparation errors to avoid

  • Failing to count part-time employees consistently, causing misapplication of thresholds and unexpected coverage.
  • Using incorrect site addresses or missing local official recipients, which can invalidate the notice service.
  • Not documenting internal decision-making or relying on unsigned drafts, weakening legal defenses if challenged.
  • Assuming federal WARN is the only rule; state mini-WARN laws often add separate notice obligations and timelines.

eSignature provider comparison for delivering WARN notices

Select a platform that supports secure delivery, audit trails, and retention. Below is a concise pricing and capability comparison with signNow listed first.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day trial No No Yes, limited Yes, limited
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently asked questions about WARN notices

Answers to common procedural and legal questions to help avoid mistakes when preparing notices.


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