Forms Used in Processing Claims

• Claim for Benefits / Claim for Benefits - FAQ
• Amputation Chart - Foot (Form 7)
• Amputation Chart - Hand (Form 7)
• Attending Physician's Report (Form 6)
• Award Agreement
• Supplemental Agreement to Pay Varying Temporary Partial Benefits (Form 4G)
• COLA Request Form (CA51)
• Employer's Application for Hearing (Form 5A)
• Expedited Hearing Request Form
• Fatal Award Agreement
• Peer Review Program Overview (Form PR51)
• Peer Review Form (Form PR50)
• Termination of Wage Loss Award
• Wage Chart (Form 7A)
  - example of properly completed form
  - example of properly completed form with an 8 day (or more) gap - NOTE: If an injured employee lost more than seven consecutive calendar days, although not in the same week, these periods should be noted on the wage chart using an asterisk (*) in the "Gross amount paid, including over time" column. §65.2-101.
• First Report of Injury - NOTE: This form should only be filed with the Commission for pre 10/01/08 accidents that have yet to be reported to the Commission.

Subpoena Information and Forms

• Subpoena Information
• Letter to Sheriff
• Subpoena Duces Tecum--Attorney Issued
• Subpoena Duces Tecum--Requesting Party
• Subpoena Duces Tecum--VWC Issued
• Subpoena for the Taking of Deposition
• Witness Subpoena--Attorney Issued
• Witness Subpoena--VWC Issued

Employers' Insurance Monitoring Forms

• Certificate of Workers’ Compensation Insurance (Form 61A)
• Contractor Information Sheet
• Notice Terminating Prior Rejection of Coverage (Form 17A)
• Rejection of Coverage (Form 16A)
• Waiver of Occupational Disease (Form 9A)
• Referral for Lack of Coverage
• PEO Parental Guarantee

Self-Insurance Forms

• Application for Individual Self-Insurance (Form 20)
• Letter of Credit
• Overview of Self-Insurance Requirement (Form SI23)
• Parental Guarantee (Form 22)
• Self Insurance Bond (Form 21A)

Taxation Forms

• Annual Payroll Report of City, Town or County Operating as a Self-Insurer (Form 26C)
• Annual Report of Premiums, Assessments, Etc., Received by Insurance Carriers (Form 26A)
• Annual Report of Self-Insurer's Payroll (Form 26)
• Annual Report of Self-Insurer’s Payroll by City, Town or County School Boards (Form 26B)

Petition Under Virginia Birth-Related Neurological Injury Act

• Petition Under Virginia Birth-Related Neurological Injury Act (Form BR1)

Workplace Notices

• Employer's Workplace Notice (Form 1)
• Noticia Sobre Compensación Laboral (Employer's Workplace Notice - Spanish Version)
• Notice Risk to Coal Miners (Form VWC-1B)

Settling a Case by Petition & Order (P&O)

• Claimant's Affidavit
• Informational Letter Where Employee IS NOT Represented by Counsel
• Information Letter Where Employee is NOT Represented by Counsel and Settlement Contains a BLANKET RELEASE
• Letter for Beneficiary in Fatal Case
• Sample Order
• Sample Petition