Fill and Sign the Va Lump Form

VWC Claim No                         Carrier No       1. Name and present address of the beneficiary-             2. The existing award of the Commission provides for the payment of compensation at the rate of $       week for a period of       3. Compensation on the foregoing award has been paid for       weeks to             5. The amount of the lump sum requested is $       Date at             this                          VWC *1 2A COMMONWEALTH OF VIRGINIA VIRGINIA WORKERS' COMPENSATION COMMISSION 1000 DMV DRIVE, RICHMOND, VA 23220 Claimant Agreement for the Settlement of an Award VS. Employer in a Lump Sum or Partial Lump Sum. Insure r The parties in the above styled case have agreed to settle the existing award of the Worker's Compensation Commission in a lump sum and request the approval of such agreement. For the information and guidance of the Commission the following facts are agreed to: per weeks . Date 4. The purpose for which the lump sum is requested is: (Here must be given a full and accurate account of the proposed use of the lump sum in order that the Commission may pass upon whether or not it is to the best interest of beneficiary.) Note: A 4% discount, compounded annually, will be calculated by the Commission and deducted from the above amount pursuant to §65.2-522, Code of Virginia . 6. The beneficiary agrees to give any further information or to comply with any reasonable requirements that the Commission may need. (Employer) day of By (Beneficiary)