Change In Condition Claims Response Form

PDF icon 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.

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.
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  • FAX: Fax the complete form to 804-823-6904
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  • MAIL: Mail the completed form to 333 E. Franklin St., Richmond, VA 23219
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  • 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.