Fill and Sign the Employers Application for Hearing Form

Employer’s Application for Hearing SEE SPECIAL INSTRUCTIONS ON THE REVERSE SIDE JCN Date of Accident Virginia Workers’ Compensation Commission 333 E. Franklin St., Richmond, Virginia 23219 Employee Address City/State/Zip The Commission is request ed to suspend benefits for the following reason(s) [attach supporting documentation]: The employee returned to pre -injury work on _ _ . The employee was released to return to pre -injury work on _ _ per Dr. ´s report dated _ _ . The employee returned to light -duty work on _ __ at an average weekly wage of $ . The employee’s current disability is unrelated to the industr ial accident noted in Dr. ´ s report(s) dated _ _ . The employee failed to report to an employer -requested medical examination with Dr. on _ _ . The employee refused selective employment within the employee’s physical capacity at on _ _ . The employee failed to cooperate with vocational rehabilitation efforts (documentation must be attached). The employee has refused medical treatment offered by Dr. as noted in the medical report dated _ . Other Request: Termination/suspension of the outstanding award Change of an outstanding award for temporary total to temporary partial Credit Other Compensation was paid through _ _ at the rate of $ per week. I hereby certify under penalty of perjury that the statements in this application are true and correct to the best of my k nowledge and that a copy of this application , INCLUDING INSTRUCTIONS ON THE REVERSE SIDE, and all attached supporting documents were sent to the employee at the above address, and to the employee’s attorney (if known) at __________________________________ ____________, and to the Virginia Workers’ Compensation Commission on _______________ (date). APPLICANT’S NAME AND TITLE: __________________________________EMPLOYER/CARRIER______________________________ SIGNATURE OF APPLICANT: _________________________ _____________DATE:____________________________________________ Registered WebFile Users: type in your signature if submitting through your WebFile account. Notice to the employee: If the Virginia Workers’ Compensation Commission approves this application, your compensation benefits will be suspended. Please refer to the additional instructions on the back of this form. Employer’s Application for Hearing VWC Form No. 5A (rev. 4/01/ 09) FILING INSTRUCTIONS (Instructions Updated 04/01/09) Employer’s Application for Hearing VWC Form No. 5A Employer Instructions: Complete the Employer’s Application for H earing (VWC Form No. 5A) on the reverse side of this form. The form must be si gned, under penalty of perjury, and sent to the Virginia Workers’ Compensation Commissi on 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 Co mmission, a copy of the application and the supporting documentation must be sent to th e 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 rely ing on Rule 1.4 (F) , please indicate that compensation benefits continue to be paid. You will be notified in writing if the Virg inia Workers’ Compensation Commission finds it appropriate to suspend compensation benef its 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 explai ning why your compensation benefits should be continued. This statement and any s upporting 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’ Co mpensation Commission determines that compensation benefits should not be suspended, you will be no tified 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 evid entiary docket or that a final decision will be made based on the written record. For questions or assistance with comple ting the form, please contact the Customer Assistance Department at 1-877-664-2566.