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 Sample Request for Review

(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.

                                              REQUEST FOR REVIEW

           COME(S) NOW (the Claimant-Name of Claimant)(the Employer-Name of Employer and the Insurer-Name of Insurer) by counsel, and request(s) review by the Virginia Workers’ Compensation Commission of the opinion issued by Deputy Commissioner (Name of Deputy Commissioner) on (date of opinion).Exception is taken to the following determinations of fact and law:

     1.

     2.

     3.

     4.  Such other errors as may become apparent upon receipt of the transcript; and

     5.  The right is reserved to present additional grounds for review at the time of oral argument.

          In accordance with Rule 3.1 of the Commission, oral argument is requested before the Full Commission. Request is further made for a copy of the transcript of the hearing before Deputy Commissioner (Name of Deputy Commissioner) held on (date of hearing).

Respectfully submitted,

(Name of Party or Parties)

By: (Signature of Party or Attorney)

 

(Name of Party or Attorney)

(Address)

(Telephone No.)

CERTIFICATE OF SERVICE

I hereby certify that a true copy of the foregoing Request for Review was mailed postage prepaid to (Party or Attorney), (Address), this (day) day of (month), (year).

(Signature of Party or Attorney)

(Name of Party or Attorney)

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