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Sample Designation of Medical Records, Exhibits and Deposition References

(Note: This is not an official VWC form or document, and is merely an example of a type of document which has been utilized in the past. It may not be suitable for your situation and no warranty is made regarding its reliability.)

 

VIRGINIA:

       IN THE WORKERS’ COMPENSATION COMMISSION

 

(Name of Claimant),

Claimant

v.

           V.W.C. File No.:

(Name of Employer),

Employer

and

 

(Name of Insurer),

Insurer.

 

   DESIGNATION OF MEDICAL RECORDS,

EXHIBITS AND DEPOSITION REFERENCES

          COME(S) NOW  the (Claimant)(Employer and Insurer) and submit(s) the following designation pursuant to Rule 2.2(B)(3) of the Virginia Workers’ Compensation Commission:

A. Medical Reports

                      Name of Health Care Provider              Date of Report 

1.

2.

3.

4.

5.

B. Exhibits

                      Author                   Exhibit Designation                  Date of Exhibit

1.

2.

3.

4.

5. 

C. Deposition References

      Name of Deponent           Date of Deposition           Page       Line

1.

2.

3.

4.

 

Respectfully submitted,

(Name of Claimant) or

(Name of Employer and

(Name of Insurer)

 

By: (Signature of Claimant, Claimant’s Attorney, Employer's Attorney

 

(Name of Claimant, Claimant’s Attorney

or Name of Employer/Insurer’s Attorney)

Address

Telephone Number

 

CERTIFICATE OF SERVICE

I hereby certify that a true and exact copy of the foregoing Designation of Medical Records, Exhibits and Deposition References was mailed postage prepaid to (Name of Claimant or Name of Opposing Party’s Attorney), (Address), this (day) day of (month), (year).

(Signature) 

           (Name of Party or Attorney)

 

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