Waiver of Occupational Disease (Form 9A)

Download Waiver of Occupational Disease (Form 9A)

The occupational disease waiver is used when an employee or prospective employee is affected by or susceptible to a specific occupational disease, but not incapacitated by such disease. The employee or prospective employee may, with approval of the Commission, waive compensation for an aggravation of his/her condition that may result from his/her working or continuing to work in the same or similar occupation for the same employer.

Section 65.2-407 B permits the approval of a waiver for coal worker’s pneumoconiosis and silicosis only when presented with X-ray evidence from a physician qualified in the opinion of the Commission to make the determination and which demonstrates a positive diagnosis of the pneumoconiosis or the existence of a lung condition which makes the employee or prospective employee significantly more susceptible to the pneumoconiosis.

In considering approval of a waiver, the Commission may supply any medical evidence to a disinterested physician for his opinion as to whether the employee is affected by the disease or has the preexisting condition.

The employee that files a waiver of occupational disease form should understand that by filing a waiver they are waiving their right to claim workers’ compensation benefits. The form requires a Physician’s Certification that must be completed, signed and dated by a licensed physician. The form must be completed and signed by the employee, a witness and by a representative of the employer.

The Form 9A may be submitted to the Insurance Department of the Commission via mail to: Insurance Department Virginia Workers’ Compensation Commission 333 E. Franklin St., Richmond, VA 23219

Once Insurance Department review is completed the Commission will send a duplicate copy of the form back to the submitter (generally the employer).

For questions concerning the Waiver of Occupational Disease form please call the Insurance Department of the Commission at (804) 205-3586 or email vwcinsurance@workcomp.virginia.gov.