Form 5a - Employer'S Application For Hearing Page 2
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1
2FILING INSTRUCTIONS
(Instructions Updated 04/01/09)
Employer’s Application for Hearing
VWC Form No. 5A
Employer Instructions:
Complete the Employer’s Application for Hearing (VWC Form No. 5A) on the reverse
side of this form. The form must be signed, under penalty of perjury, and sent to the
Virginia Workers’ Compensation Commission with supporting documentation. You may
submit this form with your electronic signature and supporting documentation via your
WebFile account at https://webfile.workcomp.virginia.gov. At the time the application is
filed with the Commission, a copy of the application and the supporting documentation must
be sent to the employee and to the employee’s attorney, if represented.
The employer must send the employee a copy of the “Employee Instructions” as shown
below.
Compensation must be paid in accordance with the Virginia Workers’ Compensation
Commission Rule 1.4 (C). If you are relying on Rule 1.4 (F), please indicate that
compensation benefits continue to be paid.
You will be notified in writing if the Virginia Workers’ Compensation Commission finds
it appropriate to suspend compensation benefits or if a determination is made that
compensation benefits should not be suspended pending a hearing.
Employee Instructions:
If you wish to contest the suspension of compensation benefits pending a final
determination by a deputy commissioner, you must provide the Virginia Workers’
Compensation Commission with a written statement explaining why your compensation
benefits should be continued. This statement and any supporting documentary evidence
must be received at the Commission’s office 15 days from the date of this application.
If after examining this application, the attached documentation, and the employee’s
response, the Virginia Workers’ Compensation Commission determines that
compensation benefits should not be suspended, you will be notified in writing and your
compensation benefits will immediately be resumed.
If the Virginia Workers’ Compensation Commission finds it is appropriate to suspend
benefits until a final determination can be made by a deputy commissioner, you will be
notified either that the case is being referred to the evidentiary docket or that a final
decision will be made based on the written record.
For questions or assistance with completing the form, please contact the Customer
Assistance Department at 1-877-664-2566.
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