Form 4a - Supplemental Agreement To Pay Benefits - Virginia 1999 printable pdf download

Form 4a - Supplemental Agreement To Pay Benefits - Virginia 1999

Reserved

VWC file number

Supplemental Agreement to Pay Benefits

The boxes

(formerly: Supplemental Memorandum of Agreement)

Insurer code

Insurer location

Virginia Workers' Compensation Commission

to the right

are for the

1000 DMV Drive Richmond VA 23220

Insurer claim number

use of the

SEE INSTRUCTIONS ON REVERSE SIDE

insurer

Employer

Name of employer (see Employer’s First Report)

Address

Phone number

Federal Tax Identification Number

Employee

Name of employee

Phone number

Cause of injury/ illness

Address

Date of birth

Nature of injury/ illness(incl. body parts)

Social security number

City or county where injury/illness

occurred:

Date of injury or illness

List first seven days of incapacity

Pre-injury Average Weekly Wage

Temporary Total

shall be paid per week during total incapacity, beginning

Temporary Partial

shall be paid per week during partial incapacity beginning

, based on

a current weekly wage of $

, compared to a pre-injury average weekly wage of $

Permanent Partial

shall be paid per week for a period of

weeks beginning

, based

% loss (or loss of use) of the

, payable

(body part)

(payment interval)

Employer

Print Name

Phone

Date

(

)

Signature of Employee, guardian, or committee

Print Name

Phone

Date

(

)

Insurer or authorized representative (signature of processor)

Print Name

Phone

Date

(

)

Name of Insurer

(This space reserved for Commission use)

Fee

Name and address of employee’s attorney (if represented)

Approved by

Date

This report is required by the Virginia Workers’ Compensation Act

Supplemental Agreement to Pay Benefits

VWC Form No. 4A (rev. 9/1/99)

Form 4a - Supplemental Agreement To Pay Benefits - Virginia 1999

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