Fill and Sign the Virginia Workers Compensation Form

                                                                                                          YES No                                                                                                                                           (Check here.) The parties agree to an award for payment of medical bills related to the compensable injury.                                                                               / / / / / / / / / / Agreement to Pay Benefits (formerly: Memorandum of Agreement) Virginia Workers' Compensation Commission Reserved VWC file number The boxesto the rightInsurer code Insurer location are for the 1000 DMV Drive Richmond VA 23220 use of the Insurer claim number SEE INSTRUCTIONS ON REVERSE SIDE Insurer Employer Name of employer (trading as or doing business as, if applicable) Address Phone number Federal Tax Identification Number Is this worker covered by a PEO policy Employe e Name of employee Phone number Address Date of birth Social security number Time and Place of Accident City 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 thecompensation or benefits indicated below until terminated in accordance with the provisions of the Workers' Compensation Act. Temporary $ shall be paid per week beginning based on a pre-injury Total average weekly wage of $ shall be paid per week beginning Temporary $ , the date on which claimant returned to work at a Partial weekly wage of $ compared to a pre-injury average weekly wage of $ Permanent $ shall be paid per week for weeks beginning / / Partial loss (or loss of use) of the , and a pre -injury average weekly wage of $ , based on a % This compensation shall be payable Medical 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 Fee Name and address of employee's attorney (if represented) 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) INSTRUCTIONS Agreement to Pay Benefits (formerly Memorandum of Agreement) VWC Form No. 4 1 . Fill out this form whenever a claim has been accepted as compensable. This Agreement to Pay Benefits provides the basis for the initial award of compensation, and contains sufficient information to establish the essential elements of a compensable claim. Submit the form to the Virginia Workers' Compensation Commission, 1000 DMV Drive, Richmond VA 23220. For subsequent periods of compensation, a Supplemental Agreement to Pay Benefits (VWC Form 4A) must be filed. 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 NCCL Self-insured employers are assigned a similar five-digit number by the Virginia Workers' Compensation Commission. 4. When filling out this form, please be sure to provide a brief description of how the accident or illness occurred in the ''Cause of Accident'' box, and to indicate all parts of the body affected in the ''Nature of Injury'' box. 5. Note that compensation is paid beginning with the eighth (8th) day of disability. If the disability lasts more than 21 days, then compensation is owed retroactively for the first seven (7) days of disability. 6. 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 alternative versions of the form you develop yourself require prior approval by the Commission. Write to ''Forms'' at the listed Virginia Workers' Compensation Commission address.