Form 46 - Termination Of Wage Loss Award
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1
2Termination of Wage Loss Award
Virginia Workers’ Compensation Commission
1000 DMV Drive Richmond Virginia 23220
1-877-664-2566
Jurisdiction Claim #:
Claim Administrator #:
SEE INSTRUCTIONS ON REVERSE SIDE
Employer's Name:
Injured Worker’s Name:
Address:
Address:
City:
State:
Zip:
City:
State:
Zip:
Home Phone:
Work Phone:
(
)
-
Employer’s Phone:
Date of Injury:
Pre-Injury Average Weekly Wage:
Payment of Compensation pursuant to the open award is terminated for the reason indicated below.
(Choose A or B)
A. The Injured Worker returned to work on
at a wage equal to or greater than the pre-injury average weekly wage.
(m/d /yyyy)
B. The Injured Worker was able to return to pre-injury work on
. (Documentation supporting release must be attached.)
(m/d/yyyy)
THIS AGREEMENT IS SUBJECT TO VERIFICATION BY THE COMMISSION PURSUANT TO THE VIRGINIA WORKERS’ COMPENSATION ACT
Signatures REQUIRED
Signing this form indicates the parties agree that the injured worker returned to work at the pre-injury wage or is able to return to pre-
injury work.
Signature of Injured Worker
Print Name
Date
(m/d/yyyy)
Signature on behalf of the Employer/Insurer
Print Name
Date
(m/d/yyyy)
Print Name and Address of Claim Administrator
Phone Number
Print Name and Address of Injured Worker’s Attorney
Phone Number
This form is required by the Virginia Workers’
VWC Form #46
Compensation Commission
Rev. 10/08
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