Who must sign the termination?

Typically the claims adjuster and an authorized employer representative sign; some jurisdictions may also require claimant acknowledgment. Confirm required signatories with your carrier or state workers' compensation rules.

Can this form be signed electronically?

Yes — electronic signatures are valid under the ESIGN Act (15 U.S.C. ch. 96) and state UETA laws where adopted, provided intent, consent, attribution, and retention requirements are met.

Is notarization required?

Notarization is uncommon for a wage-loss termination but may be required in limited situations or by employer policy; check state commission rules or internal protocols before assuming notarization is optional.

What supporting documents should be attached?

Attach return-to-work notices, medical releases, payment ledgers, and settlement documents where applicable to substantiate the termination decision and to support audit reviews.

How long should I retain the record?

Follow federal retention baselines (IRS: 3 years, IRC §6501(a)) and HIPAA where relevant (45 CFR §164.530(j) — 6 years); states may require longer periods.

Can the termination be revoked?

Reopening or revocation depends on facts and state law; employers or claimants may request reopening based on new medical evidence or administrative error. Consult counsel or the state commission for formal procedures.

Electronic Signature
Templates
Other
Virginia Termination of Wage Loss Award

Virginia Termination of Wage Loss Award

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Termination of Wage Loss Award

(formerly: Agreed Statement of Fact)

Virginia Workers' Compensation Commission

1000 DMV Drive Richmond VA 23220

SEE INSTRUCTIONS ON THE REVERSE SIDE OF THIS FORM

Employer

Name of employer (see Employer's First Report)

Address

Phone number

Federal Tax Identification Number

Reserved

VWC file number

Insurer code

Insurer location

Insurer claim number

Employee

Name of employee

Address

Phone number

Social Security Number

Terms of Agreement

Payments of compensation under the outstanding award for the accident occurring on are terminated for the reason indicated below.

The employee returned to work on at a wage equal to or greater than the pre-injury average weekly wage of $

The employee was able to return to his/her pre-injury work on

The employee returned to work on at a lower-than-pre-injury wage in the amount of $ (A Supplemental Agreement to Pay Benefits must be attached and the outstanding award will be terminated and an award for temporary partial benefits will be entered.)

TOTAL AMOUNT OF COMPENSATION PAID THROUGH ABOVE DATES

TOTAL COST OF LIVING ADJUSTMENT PAID THROUGH ABOVE DATES

This agreement is subject to the Commission's approval. Signing this form is NOT a requirement for payment of compensation, and does not terminate the right to future compensation. See "Employee" section on the reverse of this form.

(This space for Commission use only)

Approved by:

Date:

Payment Record

(This space reserved for use by the insurer or employer)

Payment type

Compensation rate

Beginning date

Ending date

Total weeks paid / Amount paid

Signature of Employee, guardian, or committee

Date

Print Name

Phone

Insurer or authorized representative (signature of processor)

Date

Print Name

Phone

Name of Insurer

Third Party Administrator and Address (if applicable)

Instructions

Termination of Wage Loss Award (formerly Agreed Statement of Fact) VWC Form No. 46

Insurer or authorized representative

1. Fill out this form to report compensation payments or Cost-of-Living supplements that have ended. Submit the form to the Virginia Workers' Compensation Commission, 1000 DMV Drive, Richmond VA 23220.

2. The signatures of the employee and a representative of the employer or insurer (including the insurer's name) are required. If these signatures are missing, this form will be returned.

3. The information at the top right of the form should be provided by the insurer. Please note that the insurer code refers to the five-digit number assigned by NCCI. Self-insured employers are assigned a similar five-digit number by the Virginia Workers' Compensation Commission.

4. Check the appropriate reason for the termination of the award, and list separately at the bottom of the form the compensation paid for each period and type of payment. Do not report anything that has been previously reported. If additional space is needed, use a separate sheet of paper with the same column headings.

5. Additional copies of this form are available without cost by writing to the Commission. Please note that color coding of the forms greatly increases the Commission's efficiency in processing claims, and that any alternate versions of the form you develop yourself require prior approval by the Commission. Write to "Forms" at the listed Virginia Workers' Compensation Commission address.

Employee

The signing of this document is not a requirement for payment. Should you have any further disability, your claim can be reopened with the following limitations:

1. If the claim is for wage loss benefits, your claim must be reopened within 24 months from the last date for which compensation was paid under an Award.

2. If the claim is for permanent disability, it must be made within 36 months from the last date for which compensation was paid under an Award.

If such additional compensation is awarded at a hearing, the new period of compensation will not begin earlier than 90 days before you file an application for the hearing.

*The valid payment types are:

T - Temporary Total

TP - Temporary Partial

P - Permanent Partial (specific disability)

PT - Permanent Total

LS - Lump Sum

C - Cost-of-Living

FT - Compensation paid in a fatal claim

FE - Funeral expense

What the Virginia Termination of Wage Loss Award Is

The Virginia Termination of Wage Loss Award is the formal record used to end wage-loss benefit payments under a workers' compensation award when the injured worker returns to employment, reaches maximum medical improvement, or otherwise no longer qualifies for scheduled wage-loss benefits. It documents the effective termination date, the reason for ending benefits, and the parties' signatures or acknowledgments needed for administrative or employer records. The form aligns with state workers' compensation procedures and is used by employers, claims administrators, and hearing examiners to ensure accurate benefit accounting and to avoid overpayments.

Why a Proper Termination Record Matters

A correct termination form protects employers and claimants by creating a clear, dated record of benefit cessation and preventing overpayment disputes or administrative penalties.

Who Typically Prepares and Receives This Form

Common users include employers, insurers, claims adjusters, and vocational rehabilitation coordinators; each party relies on the termination record to manage benefits.

Employers and HR teams responsible for payroll adjustments and return-to-work records.
Claims adjusters and insurance examiners who close or adjust benefit payment streams.
Attorneys or representatives who need a permanent record for administrative hearings.

Maintain copies for audits, internal controls, and to support any subsequent disputes or reopening requests.

Key Roles Who Sign or Authorize the Form

Claims Manager

A claims manager or adjuster typically completes the form and certifies the factual basis for termination, including dates and supporting documentation, and must retain the record for audit and regulatory review.

Employer Representative

An employer or HR official acknowledges payroll and benefits adjustments, confirms return-to-work status when applicable, and signs to show employer-side acceptance of the termination action.

Step-by-Step: Completing the Termination Form

Follow these sequential steps to complete and record a termination of wage loss award correctly.

01

Gather Documentation: Collect medical release, return-to-work notice, and payment history.
02

Verify Claim Data: Confirm claim number, employee identity, and benefit period.
03

Enter Termination Details: Record date, reason, and any limitation or partial return information.
04

Sign and File: Obtain required signatures and submit to the payer and file keeper.

Typical Processing Flow After Submission

This sequence shows who receives and processes the form once completed.

Employer: Receives copy and updates payroll.
Insurer: Updates claims system and stops payments.
State Commission: Files if required by jurisdiction.
Employee: Receives notice and retains record.

Digital Workflow Configuration Checklist

Configure your digital workflow to ensure signatures, notifications, and record retention are automated.

Field	Configuration
Signature Field	Required for employer and claims adjuster
Date Field	Auto-fill MM/DD/YYYY
Attachment Field	Allow supporting docs upload
Routing Rule	Send to insurer, employer, employee

Digital Submission and eSignature Considerations

Ensure the chosen platform supports authenticated e-signatures, audit trails, secure storage, and optional notarization capabilities.

Authentication: Email, SMS, or stronger
Audit Trail: IP, timestamp, action log
Storage: Encrypted at rest

Timing and Filing Expectations

Timing for submitting a termination varies by case and state; act promptly to prevent overpayments and notice issues.

Immediate Notification:

Notify insurer as soon as wage loss stops

Internal Payroll:

Adjust payroll at next processing cycle

State Filing:

File with state commission if required

Employee Notice:

Provide dated copy to claimant

Record Retention:

Keep original for statutory period

Key Milestones from Event to Closure

Milestones chart the route from the triggering event to administrative close and record retention.

01

Trigger Event

Return-to-work or MMI documented by provider

02

Form Completion

Termination form completed and signed

03

System Update

Insurer and payroll update payment status

04

Close File

Claim closed with retained documentation

Essential Elements to Include in a Professional Termination Record

A comprehensive termination form reduces ambiguity and supports future audits, appeals, or reopening requests by including specific data points and clear signatures.

Claim Identification

Unique claim number, policy identifier, and adjuster name to allow immediate lookup in the claims system and to tie termination to the correct claim file.

Effective Date

Precise MM/DD/YYYY effective date for termination that determines payment cutoffs and overpayment calculations; use the date of return or medical release when available.

Termination Reason

Concise, factual reason (return to work, MMI, settlement) with supporting evidence references to avoid later disputes and to justify closure.

Payment Reconciliation

Summary of amounts paid, period covered, and any offsets or reimbursements required to reconcile wage-loss payments at closure.

Signatures and Dates

Signatures from required parties with printed names and dates; if electronically signed, include an auditable certificate or log.

Supporting Attachments

Attach medical notes, employer return-to-work documents, or settlement agreements that substantiate the termination decision.

Common Pitfalls to Avoid

Using inconsistent claim identifiers that prevent matching across systems and delay processing.
Missing or ambiguous termination dates that lead to overpayment disputes or calculation errors.
Failing to include supporting documentation such as a return-to-work notice or medical release.
Allowing unsigned or improperly authenticated records that may be rejected in audits or appeals.

Short-Term Risks and Long-Term Consequences

Overpayment Liability: Employer liable

Claims Reopening: Possible reopening

Regulatory Penalties: Administrative fines

Audit Exposure: Record deficiencies flagged

Legal Disputes: Increased litigation risk

Data Privacy: HIPAA concerns

eSignature Pricing and Capability Snapshot

Compare typical starting prices and capability notes for common eSignature providers; plan details and trials vary by vendor and may change by offer.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by offer	Varies by offer	Varies by offer	Varies by offer
Bulk Send	Yes (Business Premium)	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
Envelope Cap	No cap	100 envelopes/user/yr	Varies by plan	Varies by plan	Varies by plan

Frequently Asked Questions

Answers to common questions about completing, signing, and storing a Virginia Termination of Wage Loss Award.

Need help? Contact support

Who must sign the termination?
Typically the claims adjuster and an authorized employer representative sign; some jurisdictions may also require claimant acknowledgment. Confirm required signatories with your carrier or state workers' compensation rules.
Can this form be signed electronically?
Yes — electronic signatures are valid under the ESIGN Act (15 U.S.C. ch. 96) and state UETA laws where adopted, provided intent, consent, attribution, and retention requirements are met.
Is notarization required?
Notarization is uncommon for a wage-loss termination but may be required in limited situations or by employer policy; check state commission rules or internal protocols before assuming notarization is optional.
What supporting documents should be attached?
Attach return-to-work notices, medical releases, payment ledgers, and settlement documents where applicable to substantiate the termination decision and to support audit reviews.
How long should I retain the record?
Follow federal retention baselines (IRS: 3 years, IRC §6501(a)) and HIPAA where relevant (45 CFR §164.530(j) — 6 years); states may require longer periods.
Can the termination be revoked?
Reopening or revocation depends on facts and state law; employers or claimants may request reopening based on new medical evidence or administrative error. Consult counsel or the state commission for formal procedures.

Explore Templates

Provider Agreement Credit Agreement

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now