Letter for Beneficiary in Fatal Case

Download Letter for Beneficiary in Fatal Case

 A required form that unrepresented beneficiaries of a deceased worker must complete when settling a case arising out of the worker’s fatality.

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 804-823-6957.
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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.