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.
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 804-823-6904
- 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.