Insurers

 This form may be used by employers, insurers, or claims administrators to notify the ADR Department whether an injured worker’s Change in Condition Claim.

• is accepted, accepted in part and denied in part, or denied;
• the reasons for acceptance or denial, and, if denied in whole or in part;
• whether the employer, insurer, or claims administrator consents to issue mediation with the injured worker to try and resolve the claim together, with the help of a mediator, without the need for a hearing.

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.

 
Electronic filing of the Rejection of Coverage form is now available. Click here to begin completing the form.

 Electronic filing of the Notice Terminating Prior Rejection of Coverage (Form 17A) is now available. Click here to begin completing the form.

Pursuant to Code of Virginia §§ 65.2-800 and 58.1-3714 signed certifications of insurance coverage are to be provided by the contractor to the localities.

This form is used to report a work place injury to the Commission or to the Insurance Carrier/Claim Administrator depending on the date of injury. For all injuries occurring on or after October 1, 2008, this form should only be used to notify the insurance carrier/claim administrator of a work place injury. For injuries that occurred before October 1, 2008, that have not been reported to the Commission, the employer should use this form to report the injury so that Jurisdiction Claim Number can be assigned.

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.