Vwc Form No. 4 - Agreement To Pay Benefits
ADVERTISEMENT
1Reserved
VWC file number
Agreement to Pay Benefits
(formerly: Memorandum of Agreement)
The boxes
Insurer code
Insurer location
to the right
Virginia Workers' Compensation Commission
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
Address
Date of birth
Social security number
Time and Place of Accident
City or county where injury or illness occurred
Cause of injury or illness
Nature of injury or illness, including parts of body affected
Date of injury or illness
List first seven days of incapacity
Pre-injury Average Weekly Wage
Terms of Agreement
We certify that the facts relating to this accident are correct as presented on this form, and agree that the employee shall receive the
compensation or benefits indicated below until terminated in accordance with the provisions of the Workers’ Compensation Act.
$
shall be paid per week beginning
/
/
, based on a pre -injury
Temporary
average weekly wage of $
.
Total
$
shall be paid per week beginning
/
/
, the date on which claimant returned to work at a
Temporary
weekly wage of $
compared to a pre -injury average weekly wage of $
.
Partial
$
shall be paid per week for
weeks beginning
/
/
, based on a
%
Permanent
loss (or loss of use) of the
, and a pre -injury average weekly wage of $
. This compensation
Partial
shall be payable
.
Medical
_______ (Check here.) The parties agree to an award for payment of medical bills related to the compensable injury.
only
Signatures
Employer
Print Name
Phone
Date
(
)
/
/
Employee, guardian, or committee
Print Name
Phone
Date
(
)
/
/
Insurer or authorized representative (signature of processor)
Print Name
Phone
Date
(
)
/
/
Name and address of Insurer
(This space reserved for Commission use)
Name and address of employee’s attorney (if represented)
Fee
Approved by
Date
This report is required by the Virginia Workers’ Compensation Act
Agreement to Pay Benefits
VWC Form No. 4 (rev. 9/1/99)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Mbca-10mb - Agreement To Pay Dissenting Shareholders Of Domestic Corporations And Appointment Of Secretary Of State As Agent - Maine
Legal
Form Mbca-10ma - Agreement To Pay Dissenting Shareholders Of Domestic Corporations And Appointment Of Secretary Of State As Agent - Maine
Legal
Form Mbca-10mb - Agreement To Pay Dissenting Shareholders Of Domestic Corporations And Appointment Of Secretary Of State As Agent
Legal
Form Mbca-10ma - Agreement To Pay Dissenting Shareholders Of Domestic Corporations And Appointment Of Secretary Of State As Agent
Legal
Form Dr 6590 - Agreement To Pay - Individual & Sole Proprietor Application And Financial Statement
Financial
Related Categories
Parent category: Legal