Request For Expedited Hearing
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1
2REQUEST FOR EXPEDITED HEARING
CAREFULLY READ THE SPECIAL INSTRUCTIONS ON THE BACK OF THIS FORM FIRST!
After you have read the instructions, if you believe you qualify for an expedited hearing, (1) fill out
this form; (2) attach information supporting your request; and (3) send everything to:
EXPEDITED DOCKET
VIRGINIA WORKERS’ COMPENSATION COMMISSION
1000 DMV DRIVE, RICHMOND VA 23220
VWC FILE NUMBER: __________________________
(The file number is usually printed at the top
right corner of mail received from the VWC)
Employee Name:
___________________________________________
Soc. Sec. Number: ___________________________________________
Telephone Number: (____)______________________________________
YOUR
Address:
___________________________________________
City/State/Zip:
___________________________________________
APPLICATION
Name and Employment
CANNOT BE
Status of Spouse:
___________________________________________
Names and Ages
PROCESSED
of Dependents:
___________________________________________
Available assets you have (including bank accounts and
WITHOUT ALL
Social Security Disability):_____________________________________
___________________________________________________________
OF THIS
Employer’s Name: ___________________________________________
Employer’s Phone: (____)______________________________________
INFORMATION
Employer’s Address:___________________________________________
City/State/Zip:
___________________________________________
SPECIFIC BENEFITS SOUGHT:
Total wage loss for the following period: __________________________________________
Partial wage loss for the following period: __________________________________________
Other: _______________________________________________________________________
I NEED AN EXPEDITED HEARING BECAUSE OF (CHECK ALL THAT APPLY):
________
House foreclosure
________
Eviction
________
Urgent need for medical treatment
________
Car repossession
________
Other: ___________________________________________________________
I AM ATTACHING THE FOLLOWING EVIDENCE TO THIS FORM:
________
Foreclosure notice
YOUR APPLICATION WILL
________
Eviction notice
BE REJECTED WITHOUT
________
Car repossession notice
________
Doctor’s note stating medical emergency
ONE OF THESE
________
Other
ATTACHMENTS
SIGNATURE OF CLAIMANT: ____________________________ Date: _______________
REQUEST FOR EXPEDITED HEARING
VWC Form No. 5B (rev. 12/12/2003)
Virginia Workers’ Compensation Commission
REQUEST FOR EXPEDITED HEARING
Request for Expedited Hearing
VWC Form No. 5B (rev. 12/12/2003)
[Office Use: Date Filed: ______ Supp. Docs.: ______ Refer/Deny by: _____ To: _____ Date:______ ]
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