Form Vwc Form 5a - Employer'S Application Form For Hearing

ADVERTISEMENT

Employer’s Application for Hearing
Virginia Workers’ Compensation Commission
1000 DMV Drive, Richmond VA 23220
SEE SPECIAL INSTRUCTIONS ON THE REVERSE SIDE
Employee
JCN
Address
Date of Accident
City/State/Zip
The Commission is requested to suspend benefits for the following reason(s) [attach supporting documentation]:
The employee returned to pre-injury work on
_
_
.
The employee was released to return to pre-injury work on
_
_
per Dr.
´s report dated
_
_
.
The employee returned to light-duty work on
_
__
at an average weekly wage of
$
.
The employee’s current disability is unrelated to the industrial accident noted in
Dr.
´s report(s) dated
_
_
.
The employee failed to report to an employer-requested medical examination with
Dr.
on
_
_
.
The employee refused selective employment within the employee’s physical capacity at
on
_
_
.
The employee failed to cooperate with vocational rehabilitation efforts (documentation must be
attached).
The employee has refused medical treatment offered by Dr.
as noted
in the medical report dated
_
.
Other
Request:
Termination/suspension of the outstanding award
Change of an outstanding award for temporary total to temporary partial
Credit
Other
Compensation was paid through
_
_
at the rate of $
per week.
I hereby certify under penalty of perjury that the statements in this application are true and correct to the best of my knowledge and that a
copy of this application , INCLUDING INSTRUCTIONS ON THE REVERSE SIDE, and all attached supporting documents were sent to
the employee at the above address, and to the employee’s attorney (if known) at ______________________________________________,
and to the Virginia Workers’ Compensation Commission on _______________ (date).
APPLICANT’S NAME AND TITLE: __________________________________EMPLOYER/CARRIER______________________________
SIGNATURE OF APPLICANT: ______________________________________DATE:____________________________________________
Registered WebFile Users: type in your signature if submitting through your WebFile account.
Notice to the employee: If the Virginia Workers’ Compensation Commission approves
this application, your compensation benefits will be suspended. Please refer to the
additional instructions on the back of this form.
Employer’s Application for Hearing
VWC Form No. 5A (rev. 4/01/09)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2