Fill and Sign the Worker Adjustment and Retraining Notification New York Form

DOL FORM 22 (Rev. 6/10) State File No. DEPARTMENT OF LABOR Ins. Co. File No. WORKERS’ COMPENSATION DIVISION Date of Injury www.labor.vermont.gov AGREEMENT FOR PERMANENT PARTIAL or PERMANENT TOTAL DISABILITY COMPENSATION 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 to tal disability beginning on , 20 or no lost time. WEEKLY COMPEN SATION RATE Employee’s average weekly wage (AWW) before the accident was $ S/he is entitled to compensation at the rat e of 66 2/3 percent of said AWW or $ per week. This is upda ted 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 servi ces and supplies in accordance with 21 VSA§640. PERMANENT PARTIAL or PERMANENT TOTAL DISABILITY Employee is entitled to: Permanent Partial Disability Permanent Total Disability At the end of temporary total or temporary partial, on the day of 20 the employee having either returned to work or reached an end medical result 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 c onsidered 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