Fill and Sign the Virginia Workers Compensation 497427945 Form

VWC FILE NUMBER                                                            No Claimant's Employer's workers' compensation insurance carrier is       Accident: Accident Date:       Location of accident City or County:             How did the accident occur?       Nature of the injury:       Disease: Date doctor told claimant the disease was caused by work:       Name of Doctor:       Nature or name of the disease:       Date of last time exposed to cause of disease at work:       Date you last work for this employer-       From:       From:       From:                                                             Compensation for permanent disability Payment of lifetime medical costs for this injury and/or disease Payment of specific medical bills (attach to this form) related to this injury and/or disease Death benefits to dependents or funeral expenses Other - Specify:                                                 Please send completed form to: VIRGINIA WORKERS' COMPENSATION COMMISSION 1000 DMV DRIVE, RICHMOND VA 23220 CLAIM FOR BENEFITS FILL OUT THIS FORM COMPLETELY. MEDICAL REPORTS SHOULD BE FILED WITH THIS CLAIM OR AS SOON AS POSSIBLE. SEE SPECIAL INSTRUCTIONS ON REVERSE SIDE. (The file number is usually printed at the top right corner of mail received from the VWC.) Employee Name Phone Number Address Soc. Sec. No. City/State/Zip. Employer's Name Phone Number Address City/State/Zip Have you ever received an award or any compensation payments for this accident or disease? Yes Claimant's average gross weekly wage at the time of the accident or diagnosis of the disease was $ 1. Complete this section describing accident or occupational disease or both: State: 2. What specific benefits are you seeking? Check all that apply. Compensation for total wage loss for the periods listed below: To: To: To: Compensation for partial wage loss for the periods listed below: From: To: From: To: From: To: SIGNATURE OF CLAIMANT: Date: Phone: 0ffice use: Filed Last paid Docket for o n b y Claim For Benefits VWC FORM NO. 5 (rev. 9/1/00) -Claim for Benefits VWC Form No. 5 (rev. 9/ 1 /00) Virginia Workers' Compensation Commission INSTRUCTIONS Filing a claim: EVEN IF YOU HAVE ALREADY RECEIVED BENEFITS FROM YOUR EMPLOYER OR INSURER, YOU MUST FILE A CLAIM WITH THE VIRGINIA WORKERS' COMPENSATION COMMISSION IN ORDER TO PROTECT YOUR RIGHT TO BENEFITS UNDER VIRGINIA LA W. FILE THIS FORM WITH THE COMMISSION AS SOON AS POSSIBLE. Complete as many of the questions on the reverse side as you can. If you do not know the answer, write ''unknown'' in the blank. Write ''Attention APP'' on the mailing envelope to help us process your claim more quickly. Send a copy of the completed form to your employer. Special instructions on attachments: 1. If your claim has been denied, attach a copy of the denial letter. 2 If you are applying for benefits for permanent disability, attach the medical report which states the permanency rating and that you have reached maximum medical improvement. 3 If you are requesting payment of specific medical bills, attach copies of those itemized bills. 4. If you are applying for death benefit to dependents, attach: a. Copies of the birth certificates for each dependent for whom you seek benefits. b. A copy of the marriage license if you seek benefits for a spouse. c A copy of the death certificate. 5. If you are applying for reimbursement of funeral expenses, attach a copy of the bill(s), IMPORTANCE OF MEDICAL RECORDS: Medical reports showing that your accidental injury or disease is work related must be filed with the Commission before processing of your claim can be completed. File these medical reports with your claim or as soon as possible. If you are unable to obtain copies of your medical reports and bills, you may request a subpoena by sending the name and address of the medical provider to the Clerk of the Virginia Workers' Compensation Commission. A $12.00 check or money order made payable to the Sheriff of the city or county where the medical provider is located must be included for each subpoena. The Commission cannot issue subpoenae outside Virginia.