The treating physician completes this form to provide information to support an injured worker’s claim which resulted in amputation to the foot, toes or metatarsal bones and/or hand, fingers or metacarpal bones.
The physician should complete this form with a straight line drawn at the exact point of amputation. Circles are not acceptable. This will allow the Commission to determine an accurate entitlement of permanent partial disability benefits.
This form may be filed with the Commission in the following ways:
- ONLINE: WebFile users may upload this form through their account. Click here to learn more about WebFile.
- FAX: Fax the complete form to 804-823-6956.
- MAIL: Mail the completed form to 333 E. Franklin St., Richmond, VA 23219.
- IN PERSON: Bring the completed form to any of our VWC Office Locations.
For questions, please contact the Commission toll-free at 1-877-664-2566 or by email at Questions@workcomp.virginia.gov.