The forms below are relevant to PEOs.
Click here to view documents for PEOs.

Request for Issue Mediation

 This form may be used by injured workers, deceased worker claimants, medical provider claimants, employers, insurers, claim administrators, and legal counsel to request Issue Mediation by a Commission mediator as a means of resolving a claims dispute. Filing instructions are included on the form. Once the form is received, ADR Department staff will contact all other parties to confirm whether they are also interested in mediating the dispute.

Medical Care Provider Application Response Form

 This form may be used by employers, insurers, or claims administrators to notify the ADR Department whether a Medical Provider Application

  • is or will be accepted and paid;
  • is under review for repricing, negotiation, or other reason; or
  • is denied and for what reason; and
  • whether the employer, insurer, or claims administrator consents to issue mediation with the medical provider to try and resolve the claim together, with the help of a mediator, without the need for a hearing.

 

Change In Condition Claims Response Form

 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.

PEO Parental Guarantee

The PEO Parental Guarantee form is required to be completed when a professional employer organization (PEO) registers as a PEO in Virginia and there exists a business entity with a controlling ownership interest in the PEO or sharing common ownership with the PEO. By completing the PEO Parental Guarantee the parent company guarantees the performance of all obligations of the PEO under the Workers’ Compensation Act, including the payment of workers’ compensation benefits.