Mediation participants may use this form to provide feedback to the ADR Program Manager on mediator performance, mediation case management, and suggestions for enhancing program services. The information provided will not be used in any personnel matter.
This form is to be completed by the claim administrator when the injured worker returns to work at the pre-injury wage or is able to return to pre-injury work. Check the appropriate reason for the termination of the Award and provide the return to work date and wage information, if applicable. If the basis for terminating benefits is for reasons other than what is contained on this form, you may need to file an Employer’s Application for Hearing (VWC Form No. 5A) to terminate the outstanding Award. This form may not be modified to meet a specific case, or the form will be rejected.
In Virginia, when a claimant is under an open or ongoing Award of compensation benefits, an employer who wishes to suspend or terminate the payment of such benefits must file an application and/or termination of wage loss form with the Commission. Failure to do so could result in the employer/insurer being required to pay additional compensation benefits along with penalties and/or other sanctions.
The injured worker must file a COLA Request Form every year in order to apply for the applicable cost of living adjustments.
This form is to be completed by the claim administrator whenever a claim has been accepted as compensable and the injured worker is entitled to an award. This Award Agreement provides the basis for the award of compensation and contains sufficient information to establish the essential elements of a compensable claim. For subsequent periods of compensation benefits, this form should be used each time the injured worker’s wage loss period and compensation rate differ.
The treating physician completes this form and the report provides specific medical information including date of accident, diagnosis, prognosis, the disability period(s), and the extent of any permanent disability. This form must be signed by the treating physician.
In cases of amputation for hand/foot, the treating physician completes this form and may fill out the Amputation Chart.
