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Virginia Form Center -

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Form

Description

3.pdf First Report of Injury
4.pdf Award Agreement
5.pdf Claim for Benefits
7a.pdf Wage Chart
9a.pdf Waiver of Occupational Disease
35.pdf Fatal Award Agreement
46.pdf Termination of Wage Loss Award
6.pdf Attending Physician's Report
amputation_foot.pdf Form 7 - Amputation Foot - Chart
amputation_hand.pdf Form 7 - Amputation Hand - Chart
50.pdf Request for Peer Review
medprovinq.pdf Medical Provider Inquiry
ca51.pdf Cost of Living Adjustment Request Form
siapplication.pdf Application for Individual Self-Insurance
SIbond.pdf Self Insurance Bond
loc.pdf Irrevocable Letter of Credit
22.pdf Parental Guarantee
23A.pdf Self-Insurance-Survey-Commercial
23B.pdf Self-Insurance Survey - Government
26.pdf Annual Report of Self-Insurer's Payroll
16a.pdf Rejection of Coverage
17a.pdf Notice Terminating Prior Rejection of Coverage
26A.pdf Annual Report of Premiums, Assessments, Etc., Received by Insurance Carriers
26B.pdf Annual Report of Self-Insurer's Payroll by City, Town or County School Boards
26C.pdf Annual Payroll Report of City, Town or County Operating as a Self-Insurer
CA51A.pdf Fatal SSA Verification
webfileattyreg.pdf WebFile Attorney Registration Form
infoltrnocounsel.pdf Informational Letter Where Employee IS NOT Represented by Counsel
fatalformltr.pdf Letter for Beneficiary in Fatal Case Informational Form Letter for a BENEFICIARY who is NOT Represented by Counsel
sheriff_ltr.pdf Letter to Sheriff
requestmediation.pdf Request for Mediation
mediationconfirm.pdf Mediation Confirmation Form
mediationconsent.pdf Mediation Consent Form
adreval.pdf ADR Mediator Evaluation Form
5a.pdf Employer's Application for Hearing
req4hearing.pdf Expedited Hearing Request Form
prehearingmotion.pdf Pre-Hearing Motions Order
prehearingclaimant.pdf Pre-Hearing Statement Order - Claimant's Claim for Benefits
prehearingemployer.pdf Pre-Hearing Statement Order-Employer's Application
prehearingmedcare.pdf Pre-Hearing Statement Order-Medical Care Provider's Application
sample-info-letter.pdf Sample Informational Letter
sample-info-letter-fatal.pdf Sample-Informational-Letter-Fatal-Case
sampleaffidavit.pdf Sample Affidavit
sample-order.pdf Sample Order
claims_response_form.pdf Change in Condition Claims Response Form
subpductec_req_party.pdf Subpoena Duces Tecum - Requesting Party
subpoena_duces_tecum.pdf Subpoena Duces Tecum - VWC Issued
subp_depos.pdf Subpoena for the Taking of Deposition
ADPA2.pdf Subpoena Duces Tecum -Attorney Issued
witn_atty.pdf Subpoena for Witness - Civil - Attorney Issued
wit_subpoena.pdf Subpoena for Witness - VWC Issued
61a.pdf Contractor's Certificate of Workers' Compensation Insurance
Claimants-Affidavit.pdf Claimants Affidavit
BR1.pdf Petition Under the Virginia Birth-Related Neurological Injury Compensation Act
62.pdf Referral for Lack of Coverage Form
peoparental.pdf PEO Parental Guarantee
medproviderapp.pdf Medical Care Provider Application Response Form
GSIA.pdf Application for License as Group Self-Insurance Association
95.pdf PEO Web File Access Request Form
employers_guide.pdf BROCHURE - Notice to Employer Regarding Obligations Under Virginia WC Act
employees_guide.pdf BROCHURE - Injured Workers Guide
employees_guide_sp.pdf BROCHURE - Injured Workers Guide (Spanish)
Transmission-Profile.pdf Electronic Transmission Profile Receiver's Specifications
Trading-Partner-Profile.pdf Electronic Trading Partner Profile
Trading-Partner-Agreement.pdf Electronic Partnering Agreement
vwc1.pdf POSTER - Workers' Compensation Notice
1sp.pdf POSTER - Noticia Sobre Compensacion Laboral
CoalMinesNotice.pdf POSTER - Notice to Employee - Coal Miners