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  • Va Vwc Pneumoconiosis Claim Form 2019

Get Va Vwc Pneumoconiosis Claim Form 2019-2025

(JCN) Claim Administrator Number Injured Worker Information Name Primary Phone/Alternate Phone Address City State Zip Code Part A (Required) Employer Information Name of Company County of Work (Mine) Location Address City Date of Communication State Last Date Worked Zip Code Date of X-ray Last employer for whom 90 shifts were worked, prior to communication Did you work after this date of communication? Yes No If yes, please indicate employer below I hereby file this claim.

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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.

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.

After calculating your average weekly wage, you would be eligible for two-thirds of that wage (or the maximum rate, whichever is lower). For example, if your pre-injury average weekly wage was $900, then you are entitled to $600 in benefits, which is two-thirds of your average weekly wage.

After the Deputy Commissioner approves the settlement, which typically takes two weeks after the settlement documents are submitted to the Virginia Workers' Compensation Commission, the insurance company has 44 days to put your settlement check in the mail.

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.

Is There a Limit to the Amount of Money You Can Receive from Workers' Compensation in VA? Except in cases of permanent total disability, injured workers are generally entitled to a maximum of 500 weeks of workers' compensation benefits.

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.

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.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232