Get Vermont Dol Form 16

Filling out the Vermont Dol Form 16 online is an essential process for individuals involved in a workers' compensation settlement. This guide provides a clear, step-by-step approach to help users navigate the form efficiently and accurately.

Follow the steps to complete the form with ease.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Start by entering the state file number and the insurance company file number at the top of the form. These details help identify the specific case.
3. Provide the date of the injury. This is crucial as it marks the beginning of the claims process.
4. Complete the section detailing the name and address of the injured worker. Accurate information is key to ensure proper communication.
5. Indicate the name of the employer and the insurance carrier in the provided fields.
6. Fill in the date when the agreement occurs, ensuring this date reflects the current agreement timeline.
7. Describe the injury sustained by the worker in the designated field. Be specific to avoid any confusion regarding the nature of the injury.
8. Select the type of disability: temporary total, permanent total, temporary partial, or permanent partial, as applicable.
9. Input the beginning date of the disability benefits, ensuring it is relevant to the injury date.
10. Declare the average weekly wage prior to the accident. Remember, the insurance company must have a filed wage statement.
11. Clearly state the lump sum amount agreed upon in the settlement of the benefits being closed out. Specify the benefits involved such as indemnity, medical, or vocational rehabilitation.
12. If payments are to be made in a lump sum, specify the terms and any agreements regarding the lump sum payment, including monthly equivalent if necessary.
13. Ensure to have the applicable signatures from both the insurance carrier/employer and the employee along with official titles.
14. Finally, once the form is completed, save your changes. You can download, print, or share the form as needed.

Complete your Vermont Dol Form 16 online today to ensure a smooth filing process.