Vwc Form 5 - Claim For Benefits Page 2
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1
2Claim for Benefits
VWC Form #5
Filing Instructions
1. If you have been paid by your employer or claim administrator for time missed from work
because of your injury or for medical treatment for your injury, you must file a claim with the
Virginia Workers’ Compensation Commission to protect your right to benefits under Virginia law.
Even if you are not requesting specific benefits at this time, you should still submit this form
with Part A completed within two years of the date of your accident or diagnosis of disease.
2. If you are requesting specific benefits or if the claim administrator has denied your claim,
complete Part B of this form and submit the medical reports either attached to the form, or as
soon as possible.
You may obtain copies of your medical records directly from your physician.
Importance of Medical Records:
Medical records showing that your accidental injury or disease is work related must be filed
with the Commission. File these medical records with your claim or as soon as possible. If
you are unable to obtain copies of your medical reports and bills, you may request a
subpoena by sending the name and address of the medical provider to the Clerk of the
Virginia Workers’ Compensation Commission. A $12.00 money order made payable to the
Sheriff of the city or county where the medical provider is located must be included for each
subpoena. The Commission cannot issue subpoenae outside Virginia.
3. The parties are advised that Mediation and ADR services may be available upon request. For
further
information
contact
804-205-3139,
toll-free
877-664-2566,
or
visit
4. For questions or assistance with completing this form, please contact the Virginia Workers’
Compensation
Commission
toll
free
at
1-877-664-2566
or
visit
our
website
at
Benefits Covered under the Virginia Workers’ Compensation Act:
• Lifetime Medical Benefits – Payment for expenses related to the injury or occupational disease.
Includes payment/reimbursement of out of pocket medical, prescription and transportation expenses.
• Wage Loss Replacement (Temporary Total/Temporary Partial Disability): Full or partial wage loss
replacement for medically authorized disability from work.
• Permanent Partial Disability – Compensation for loss of use of a body part, loss of hearing/vision,
amputation, lung disease or bodily disfigurement/scarring.
• Permanent Total Disability – Lifetime wage replacement for loss of both hands, arms, feet, legs, eyes or
any two in the same accident, or is paralyzed or disabled from a severe brain injury.
• Death Benefits – In cases where injury results in death, surviving spouse, children, or certain other
dependants may be entitled to wage loss replacement benefits and payment of funeral/transportation
expenses.
• Other: Mileage reimbursement, Cost of Living Increases, if eligible. (total wage loss and fatal benefits)
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