Virginia > Workers Compensation
Employers Application For Hearing 5A - Virginia
| Employers Application For Hearing Form. This is a Virginia form and can be used in Workers Compensation . |
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Virginia Workers Compensation Commission Employers Application for Hearing 1000 DMV Drive, Richmond VA 23220 SEE SPECIAL INSTRUCTIONS ON THE REVERSE SIDE Employee VWC No. Address Date of Accident City/State/Zip The Commission is requested to suspend benefits for the following reason(s) [attach supporting documentation]: The employee returned to pre-injury work on / / . The employee was released to return to pre-injury work on / / per Dr. s report dated / / . The employee returned to light-duty work on / / at an average weekly wage of $ . The employees current disability is unrelated to the industrial accident noted in Dr. s report(s) dated / / . The employee failed to report to an employer-requested medical examination with Dr. on / / . The employee refused selective employment within the employees physical capacity at on / / . The employee failed to cooperate with vocational rehabilitation efforts (documentation must be attached). The employee has refused medical treatment offered by Dr. as noted in the medical report dated / / . Other Request: Termination/suspension of the outstanding award Change of an outstanding award for temporary total to temporary partial Credit Other Compensation was paid through / / at the rate of $ per week. I hereby certify that the statements in this application are true and correct to the best of my knowledge and that a copy of this application , INCLUDING INSTRUCTIONS ON THE REVERSE SIDE, and all attached supporting documents were sent to the employee at the above address, and to the employees attorney (if known) at ______________________________________________, and to the Virginia Workers Compensation Commission on _______________ (date). APPLICANTS NAME AND TITLE: __________________________________EMPLOYER/CARRIER______________________________ SIGNATURE OF APPLICANT: ______________________________________DATE:____________________________________________ Subscribed and sworn before me this ______ day of _______________________,_________. ______________________________________________________ My commission expires ________________. NOTARY Notice to the employee: If the Virginia Workers Compensation Commission approves this application, your compensation benefits will be suspended. Please refer to the additional instructions on the back of this form. [Office Use: Filed ____________ Last paid _____________ Docket for ___________ on ___________ by _______] Employers Application for Hearing VWC Form No. 5A (rev. 9/1/99) <<<<<<<<<********>>>>>>>>>>>>> 2 Employers Application for Hearing VWC Form No. 5A (rev. 9/1/99) Virginia Workers Compensation Commission Instructions for the Employer Complete the reverse side of this form. The form must be signed, notarized, and sent to the Commission with supporting documentation. At the time the application is filed with the Commission, a copy of the application and the supporting documentation must be sent to the employee and to the employees attorney, if represented. The employer must send a copy of the Instructions for the Employee shown below. Compensation must be paid in accordance with Commission Rule 1.4 C. If you are relying on Rule 1.4 F, please indicate that benefits continue to be paid. You will be notified in writing if the Commission finds it appropriate to suspend benefits or if a determination is made that benefits should not be suspended pending a hearing. Instructions for the Employee If you wish to contest the suspension of benefits pending a final determination by a deputy commissioner, you must provide the Commission with a written statement explaining why your benefits should be continued. This statement and any supporting documentary evidence must be received at the Commissions office 15 days from the date of this application. If after examining this application, the attached documentation, and the employees response, the Commission determines that benefits should not be suspended, you will be notified in writing and your benefits will immediately be resumed. If the Commission finds it is appropriate to suspend benefits until a final determination can be made by a deputy commissioner, you will be notified either that the case is being referred to the evidentiary docket or that a final decision will be made based on the written record.
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