Certificate Of Dependency And Concurrent Employment {10}

Vermont Department of Labor Workers' Compensation PO Box 488 Montpelier, VT 05601-0488 (802) 828-2286 www.labor.vermont.gov Form 10 (rev 9/11) State File # Ins. Co. File # Date of Injury Certificate of Dependency and Concurrent Employment Employee: Employer: TO THE EMPLOYEE: This form MUST be completed in every workers' compensation case in which an injured worker has lost time from work as the result of a work-related injury. The form must be completed even when the injured worker has no dependents. The information must be supplied and the form signed by the injured worker. This information is required to determine the employee's right to additional weekly compensation of $10.00 for each dependent child under the age of twenty-one (21) years. List below your dependent child(ren) up to 21 years old that have not already been declared by your spouse on his/her current workers' compensation claim.** Name of Dependent Date of Birth Relationship Concurrent employment: If you were working for more than one employer on the date of injury indicated above please provide the following information.** Name of Employer Employer's Address Employer's Phone Number Date of Hire I hereby certify that the above is a true, complete and accurate statement of my dependents and concurrent employment. Employee Signature Date Signed Address Telephone Number City/State/Zip **Attach additional sheets if necessary and return this to the insurance carrier American LegalNet, Inc. www.FormsWorkFlow.com