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Termination Of Wage Loss Award 46 - Virginia
|Termination Of Wage Loss Award Form. This is a Virginia form and can be used in Workers Compensation .||
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Termination of Wage Loss Award Virginia Workers' Compensation Commission 1000 DMV Drive Richmond Virginia 23220 1-877-664-2566 SEE INSTRUCTIONS ON REVERSE SIDE www.workcomp.virginia.gov Jurisdiction Claim #: Claim Administrator #: Injured Worker's Name: Address: Employer's Name: Address: State: Work Phone: ( Zip: ) - City: Home Phone: City: Employer's Phone: State: Zip: Date of Injury: Pre-Injury Average Weekly Wage: Payment of Compensation pursuant to the open award is terminated for the reason indicated below. (Choose A or B) A. The Injured Worker returned to work on (m/d /yyyy) at a wage equal to or greater than the pre-injury average weekly wage. B. The Injured Worker was able to return to pre-injury work on (m/d/yyyy). (Documentation supporting release must be attached.) THIS AGREEMENT IS SUBJECT TO VERIFICATION BY THE COMMISSION PURSUANT TO THE VIRGINIA WORKERS' COMPENSATION ACT Signatures REQUIRED Signing this form indicates the parties agree that the injured worker returned to work at the pre-injury wage or is able to return to preinjury work. Signature of Injured Worker Print Name Date (m/d/yyyy) Signature of Claim Administrator Print Name Date (m/d/yyyy) Print Name and Address of Claim Administrator Phone Number Print Name and Address of Injured Worker's Attorney Phone Number This form is required by the Virginia Workers' Compensation Commission y VWC Form #46 Rev. 10/08 American LegalNet, Inc. www.FormsWorkFlow.com Termination of Wage Loss Award VWC Form #46 Filing Instructions Claim Administrator or Authorized Representative: 1. This form is to be completed when the Injured Worker returns to work at the pre-injury wage or is able to return to preinjury work. Submit the completed for to the Virginia Workers' Compensation Commission, 1000 DMV Drive, Richmond, VA 23220. Check the appropriate reason for the termination of the Award and provide the return to work date and wage information, if applicable. If the basis for terminating benefits is for reasons other than what is contained on this form, you may need to file an Employer's Application for Hearing (VWC Form No. 5A) to terminate the outstanding Award. This form may not be modified to meet a specific case, or the form will be rejected. 2. 3. Injured Worker: Signing this document is NOT a requirement for payment. If you do not agree with the information contained and make modifications, it will be rejected. If you have any additional disability from work in the future, your claim can be reopened with the following limitations: 1. If the claim is for wage loss benefits, your claim must be reopened within 24 months from the last date for which you were entitled to compensation paid under an Award. 2. If the claim is for permanent disability, your claim must be made within 36 months from the last date for which you were entitled to compensation paid under an Award. * For questions or assistance with completing this form, please contact Customer Assistance at the Commission's toll-free number 877-664-2566.