Get Virgina Work Com Award Agreement Form Fillable

Completing the Virginia Work Com Award Agreement Form Fillable online is an important step for injured workers seeking compensation. This guide provides a clear, step-by-step approach to help users confidently fill out this form.

Follow the steps to successfully complete the Virginia Work Com Award Agreement Form

1. Click the ‘Get Form’ button to access the Virginia Work Com Award Agreement Form Fillable and open it in the editor.
2. Begin by filling out the 'Jurisdiction Claim #' field with the specific claim number assigned to your case.
3. Enter the injured worker’s name in the designated field, ensuring the spelling is correct.
4. Complete the employer's name and address section by providing their full name and physical address, including city, state, and zip code.
5. Provide the home and work phone numbers of the injured worker to ensure easy communication regarding the claim.
6. In the 'Body Parts/Injuries Accepted' section, clearly specify the accepted injuries.
7. Indicate the 'Date of Injury' accurately in the provided format.
8. In the 'Payment of Compensation' section, check all applicable benefits types, including Temporary Total, Temporary Partial, Permanent Partial, Permanent Total, and Medical Only, based on the specifics of the claim.
9. For each type of compensation selected, fill in the relevant details such as compensation rates and specific dates for periods of disability.
10. Signatures are required; make sure the injured worker and the employer/insurer sign in the designated spaces, along with their printed names and dates.
11. After reviewing all details for accuracy, save your changes. You may download, print, or share the completed form as needed.

Complete your documents online today for efficient submission and processing.