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staff. The remaining forms are examples of papers
previously filed with the VWC. The translation of the Workers' Compensation
Notice into Spanish is the work of a Spanish-speaking
consultant. The author does not pretend to be an expert in the Spanish
language. No representation or warranty whether of suitability, accuracy, reliability or otherwise regarding any of these forms or documents is made.
To view a form or document, click
on its title below.
Employer Applications: Pointers and Common Problems
By Richard F. Gorman, III
1. When alleging claimant has been released to return to work,
the carrier often fails to pay compensation through the date of filing. The
carrier/employer often erroneously pays the employee only up to the date he was medically
released.
2. Incomplete/invalid certification and notarization.
3. Employer application submitted by fax is done at the sending party's
risk.
4. Raising incorrect allegation based on the specific
evidence submitted with the application. Additionally, the application must
have evidence submitted with it.
5. When indicating on an Employer application the rate at which
compensation was last paid, the rate indicated must coincide with the weekly amount of the
Commission's current outstanding award.
6. In raising an allegation of refusal of selective (light duty)
employment, at a minimum attach: (1) a medical release for light duty work; (2) a
statement from the employer that (a) the Claimant was offered work consistent with the
light duty restrictions set out by the doctor in the release and that (b) the Claimant
refused the work offered. It is advisable to have the employer write out a description of
the job offered and have this description submitted to the doctor for written approval.
Written offers to the claimant enclosing the written approval of the doctor are also
advisable.
7. Employer application can be amended within 15 days of Filing.
The opposing party, upon request, is entitled to a limited extension of time after the 15
days within which to file a response.
8. If employer/carrier is agreeable to continuing to pay compensation,
the application can be docketed for hearing pursuant to VWC Rule 1.4(F).
9. Affidavits offered in support of an Employer Application are
acceptable. Affidavits are not acceptable evidence at the hearing.
10. Vocational Rehabilitation:
1. Do not send a voluminous packet of rehabilitation
reports. Send only those reports that are relevant to the allegation of failure to
cooperate.
2. If Claimant is on an outstanding award for TTD
(Temporary Total Disability), he has no obligation independently to seek selective
employment or to market his residual capacity.
3. Specify the particulars (i.e. examples) of instances of
non-cooperation.
* REVIEW AND RE-REVIEW VWC RULE 1.4*
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Forms]
Sample Hearing Information Sheet
(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.)
Case Name:_________________________ v. _____________________________
V.W.C. File No.:____________________________
Employer’s and Insurer’s Attorney:
(Claimant’s Claim for Benefits) (Employer’s Application) filed on _______________alleges:
______Injury by Accident:
Part(s) of Body Injured:______________________________
Date of Accident:____________________
______Occupational Disease:
Disease:______________________
Date of Communication:_________________________
Communication by whom:____________________________
Date claimant last worked for defendant employer________________
______Change in Condition:
TTD/TPD/PPD:_____________________________________
Medicals:__________________________________________
______Other:_____________________________________________
_______________________________________________________________
Relief Sought:_____TTD_____TPD_____PPD_____MEDS
_____Suspension/Termination of Comp._______________________
_____Other:____________________________________
DATES:________________ thru__________________ RTW DATES:____
________________ thru__________________
________________ thru__________________
Defenses:______________________________________________________________
______________________________________________________________________
______________________________________________________________________
Stipulations: Average Weekly Wage:__________________
Period(s) of Disability:__________________________________________
Treating Physician:___________________________________
Date(s) released to light duty:____________________________________________
Date(s) released to regular duty:__________________________________________
Other Stipulations:_________________________________________
Employer's Witnesses:
Prior Award(s):________________________________________________
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Forms]
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.
(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:
Name of Health Care Provider Date of Report
1.
2.
3.
4.
5.
Author Exhibit Designation Date of Exhibit
2.
3.
4.
5.
Name of Deponent Date of Deposition Page Line
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
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).
(Name of Party or Attorney)
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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)
Sample
Notice of Appeal to the Court of Appeals
(Note: This is not an official 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
______________________,
Claimant
v.
VWC
No. -
-
______________________
Employer,
and
______________________
Insurer.
NOTICE
OF APPEAL
The Claimant, ______________________, hereby gives notice of appeal to
the Court of Appeals of Virginia from the judgment order of the Commission
entered on _____________ . The Commission decided that the Commission was without jurisdiction to
entertain Claimant’s Request for
Review of the opinion of Deputy Commissioner Herring dated ______________.
Claimant’s Request for Review of this judgment of the Chief Deputy
Commissioner has been accepted by the full Commission, and this Notice of
Appeal is filed in the event the full Commission should decide that the
_____________ judgment of the Chief Deputy Commissioner constituted a final
judgment of the full Commission. A transcript or statement of facts, testimony
and other incidents of the case will be filed with the Court of Appeals.
(Name of Claimant)
By:____________________________
Counsel
Name,
address, telephone number,
Bar Number of Counsel
CERTIFICATE
I, __________________, Esq., counsel for ________________, hereby
certify that:
- The name and address of the appellant is: __________________,
________________, ___________________, VA ________.
- The name address and telephone number of counsel for the appellant
is: ________
______________________________________________________________.
- The name, address and telephone number of counsel for appellees is:
______________, Esq., __________________, _____________________,
VA___________, ( ) _____________.
- Counsel for appellant has ordered from the Commission a transcript
of the hearing of ________________, 1999, before Deputy Commissioner
________.
- A copy of this Notice of Appeal has been mailed to all opposing
counsel and to the Clerk of the Court of Appeals this ____ day of
_______________, 1999.
___________________________________
Counsel
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of Forms]
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