Injured Workers

 Form required to be completed by unrepresented claimants settling their workers’ compensation claims that provides information necessary for the Commission to determine whether to approve the settlement.

 Example of the Affidavit required in compromise settlements which claimant must sign and have notarized.

 Example of an Order approving a compromise settlement to be prepared by attorneys and submitted to the Commission for review and approval.

 A required form that unrepresented beneficiaries of a deceased worker must complete when settling a case arising out of the worker’s fatality.

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.

Form for requesting an expedited hearing on a pending claim or application in accordance with Commission Rule 2.3.

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.