Award Agreement - Virginia Workers Compensation Commission
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1
2Award Agreement
(Agreement to Pay Benefits)
Virginia Workers’ Compensation Commission
1000 DMV Drive Richmond Virginia 23220
1-877-664-2566
Jurisdiction Claim #:
SEE INSTRUCTIONS ON REVERSE SIDE
Claim Administrator #:
Employer's Name:
Injured Worker’s Name:
Address:
Address:
City:
State:
Zip:
City:
State:
Zip:
Home Phone:
Work Phone:
(
)
-
Employer’s Phone:
Body Parts/Injuries Accepted:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Date of Injury:
Pre-Injury Average Weekly Wage:
Payment of Compensation
Check one:
Initial period
Additional period
Corrected period
(Check all that apply)
A. Temporary Total at the compensation rate of $
_____ per week. This period of disability began on
_____
.
(m/d/yyyy)
B Temporary Partial: Please select option 1 or 2 below and complete.
1 - Will be paid at the compensation rate of $
_____ per week. This period of disability began on
_____
(m/d/yyyy)
2 - Was paid an averaged weekly compensation rate of $
_____ per week from
_____ through
_____ and will continue to be
paid at a compensation rate of $
_____ per week beginning on
_____
(m/d/yyyy)
C. Permanent Partial at the compensation rate of $
per week. This period of disability began on
for _______%
(m/d/yyyy)
loss of use,
loss, or
disfigurement of the __________________. Note: Medical report(s) or amputation chart must be attached.
Do the parties agree to have this award paid in a lump sum with the 4% discount deducted?
Yes
No
D. Permanent Total the compensation rate of $
per week. This period of disability began on
.
(m/d/yyyy)
E. Medical Only. The parties agree to an award for payment of medical benefits that are reasonable, necessary, authorized and causally
related to the compensable injury.
THIS AGREEMENT IS SUBJECT TO ADJUSTMENT AND APPROVAL BY THE COMMISSION PURSUANT TO THE VIRGINIA WORKERS’
COMPENSATION ACT
Signatures REQUIRED
By signing below, we certify that the facts relating to this accident are correct as presented on this form and agree that the Injured
Worker shall receive compensation or benefits indicated until suspended in accordance with the provisions of the Virginia Workers’
Compensation Act.
Signature of Injured Worker
Print Name
Date
(m/d/yyyy)
Signature on behalf of the Employer/Insurer
Print Name
Date
(m/d/yyyy)
Print Name and Address of Claim Administrator
Phone Number
Print Name and Address of Injured Worker’s Attorney
Phone Number
This form is required by the Virginia Workers’
VWC Form #4
Compensation Commission
Rev. 10/08
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