Pneumoconiosis Claim FormVirginia Workers Compensation CommissionAccess your claim online: webfile.workcomp.virginia.govCoal Workers Pneumoconiosis/Black Lung Disease Jurisdiction Claim Number (JCN)Claim.
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How to fill out the VA VWC Pneumoconiosis Claim Form online
Completing the VA VWC Pneumoconiosis Claim Form online is a crucial step for individuals seeking benefits for coal workers' pneumoconiosis. This guide provides clear, step-by-step instructions to help you navigate each section of the form with confidence.
Follow the steps to successfully complete the claim form.
- Click ‘Get Form’ button to obtain the form and open it for completion.
- Fill in your injured worker information. Include your name, primary phone and alternate phone numbers, address, city, state, and zip code.
- Complete Part A by providing your employer information. Include the name of the company, county of work location, address, city, state, zip code, date of communication, last date worked, and date of the X-ray reading used as evidence.
- Indicate the last employer for whom you worked 90 shifts prior to the communication of diagnosis. Specify if you worked after this communication date by selecting 'Yes' or 'No' and provide the name of the employer if applicable.
- Sign and print your name in the signature field, along with the date, to confirm that you are filing this claim for benefits under the Virginia Workers’ Compensation Act.
- In Part B, if you need assistance obtaining specific benefits, check the appropriate boxes for compensation requests and provide any necessary details, including the claim jurisdiction number if already awarded.
- Once all sections are completed, make sure to save your changes, and choose to download, print, or share the form as needed.
Take action now and complete your VA VWC Pneumoconiosis Claim Form online to ensure you receive the necessary benefits.
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Get answers to your most pressing questions about US Legal Forms API.
How long does it take to get workers comp in VA?
In Virginia the workers compensation waiting period is seven (7) days. You will not receive wage loss benefits for the first seven calendar days of disability resulting from the workplace accident.
How do I check my VA workers comp case?
Please call the Commission's Customer Contact Center toll free at 1-877-664-2566 from 8:30 a.m. - 4:45 p.m., Monday - Friday, for assistance with claim information.
What does workmans comp pay in VA?
2021 Rates: Effective July 1, 2021, the maximum compensation rate will be $1,195. Effective July 1, 2021, the minimum compensation rate will be $298.75. Effective October 1, 2021, the cost of living (COLA) rate will be 1.4%.
Does workers comp pay for lost wages in Virginia?
The insurance company is required to pay you two-thirds of the average amount of money you made per week before your accident happened. Generally, you are entitled to receive up to 500 weeks of lost wage benefits, unless you are permanently and totally disabled.
What is the coming and going rule for workers comp in Virginia?
The “Coming and Going” Rule In Virginia, an employee must be injured in a work-related accident in order to receive workers' compensation benefits. In other words, the injury must arise out of or occur during the course of employment. However, the injury does not have to take place on an employer's property.
What is the uninsured employer's fund of Virginia?
The Uninsured Employers' Fund (UEF) is the funding mechanism for compensation and medical payments to injured employees or his/her dependent(s) whose employer was not properly insured at the time of the accident.
How much does workers comp pay in Virginia?
If your injury or illness is so severe that you are permanently and totally unable to work, you may be entitled to wage loss benefits for the rest of your life. The weekly payment is two-thirds (66.66 percent) of your average weekly wages prior to injury or illness.
How do I file a workers comp claim in VA?
You may file the claim: In person: Complete the Claim for Benefits Form and deliver it to any of our office locations. ... By mail: Complete the Claim for Benefits Form and mail it to: Virginia Workers' Compensation Commission, 333 E. ... By fax: Complete the Claim for Benefits Form and fax it to: 804-823-6956.
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