Form required to be completed by unrepresented claimants settling their workers’ compensation claims that provides information necessary for the Commission to determine whether to approve the settlement.

For questions please contact the Commission toll-free at 1-877-664-2566 or by email at Questions@workcomp.virginia.gov.

Filing Language Requirement:
The Virginia Workers’ Compensation Commission can only accept filings submitted in English.

VWC Form

Description

Instructions