Agreement For Temporary Compensation {32}

Vermont Department of Labo r Form 32(Rev. 12/17) Workers222 Compensatio n State File #: PO Box 488Ins. Co. File #: Montpelier, VT 05601-0488Date of In j ur y : (802) 828-2286 www.labor.ve r mont. g ov AGREEMENT FOR TEMPORARY COMPENSATION Emplo y ee Name Emplo y er Name Employee Address Employer Address Cit y State ZipCit y State Zip Da y time Phone Emplo y er222s Phone Body Part Injured/Injuries Accepted: N umber of Dependents Pre-In j ur y /Disabilit y Avera g e Weekl y Wa g e(AWW) Pa y ment of Compensation (Check One): Initial Period of Disabilit y Additional Perio d (s) of Disabilit y Da y of the week the check will be mailed to the claimant or deposited in the claimant222s accoun t A Temporar y Total Disabilit y be g an on (mm/dd/ yyyy ) at the rate of: AWW x 0.667 $ (plus $10 per dependent up to 21 y ears old)Total = $ Minimum/Maximum $ (plus $10 per dependent up to 21 y ears old) Total =$ 90% of AWW $ B Temporar y Partial Disabilit y be g an on (mm/dd/ yyyy ) at the rate of: $ or Varies Insurance Ad j uster Si g nature Print NameDate Insurance Carrie r Insurance Carrier Mailin g Address Cit y State Zip Insurance Ad j uste r Telephone Number includin g extension Emplo y ee Si g nature Print NameDate APPROVED: Date Commissioner of Labor/Desi g nee N OTICE OF POTENTIAL ELIGIBILITY FOR UNEMPLOYMENT INSURANCE BENEFITS If your TTD has been discontinued and you have a work capacity and are able and available for work, you may be eligible for Unemployment Insurance benefits. To explore your potential eligibility, you must contact the Unemployment Initial claims line at 1-877-214-3330 within 6 months of the date your temporary partial disability benefits ended [21 VSA 2471343(d)]. Further information about unemployment benefits may be found on-line at http://labor.vermont.gov/unemployment-insurance/ under the 223Unemployed224 section. If you are found eligible, you will only be paid for weeks claimed in a timely manner, made with certification of where you have searched for work y ou222re qualified and able to perform. American LegalNet, Inc. www.FormsWorkFlow.com