Vwc Form 46 - Termination Of Wage Loss Award
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1Reserved
VWC file number
Termination of Wage Loss Award
(formerly: Agreed Statement of Fact)
The boxes
Insurer code
Insurer location
to the right
Virginia Workers' Compensation Commission
are for the
1000 DMV Drive Richmond VA 23220
Insurer claim number
use of the
SEE INSTRUCTIONS ON THE REVERSE SIDE
insurer
OF THIS FORM
Employer
Name of employer (see Employer’s First Report)
Address
Phone number
Federal Tax Identification Number
Employee
Name of employee
Address
Phone number
Social Security Number
Terms of Agreement
Payments of compensation under the outstanding award for the accident occurring on
/
/
are
terminated for the reason indicated below.
1.
The employee returned to work on
/
/
at a wage equal to or greater than the
pre-injury average weekly wage of $
.
2.
The employee was able to return to his/her pre-injury work on
/
/
.
3.
The employee returned to work on
/
/
at a lower-than-pre-injury wage in the
amount of $
. (A Supplemental Agreement to Pay Benefits must be attached and the outstanding
award will be terminated and an award for temporary partial benefits will be entered.)
TOTAL AMOUNT OF COMPENSATION PAID THROUGH ABOVE DATE
$ ______________
TOTAL COST OF LIVING ADJUSTMENT PAID THROUGH ABOVE DATE $ ______________
This agreement is subject to the Commission’s approval. Signing this form is NOT
(
This space for Commission use only)
a requirement for payment of compensation, and does not terminate the right to
Approved by:
Date:
future compensation. See “Employee” section on the reverse of this form.
(
This space reserved for use by the insurer or employer)
Payment type
Compensation rate
Beginning date
Ending date
Total weeks paid
Amount paid
$
/
/
.
/
/
.
$
$
/
/
.
/
/
.
$
$
/
/
.
/
/
.
$
$
/
/
.
/
/
.
$
Signature of Employee, guardian, or committee
Date
Print Name
Phone
(
)
Insurer or authorized representative (signature of processor)
Date
Print Name
Phone
(
)
Name of Insurer
Third Party Administrator and Address (if applicable)
Termination of Wage Loss Award
VWC Form No. 46 (rev. 9/1/99)
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