Virginia > Workers Compensation
COLA-Social Security Verification Request CA51 - Virginia
| COLA-Social Security Verification Request Form. This is a Virginia form and can be used in Workers Compensation . |
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COMMONWEALTH OF VIRGINIA WORKERS' COMPENSATION COMMISSION 1000 DMV DRIVE, RICHMOND VA 23220 www.workcomp.virginia.gov 1-877-664-2566 Date of this notice: US Social Security Administration - Benefits vs. Accident Date: File No.: Please provide the requested information in order that we may determine entitlement to cost of living adjustment for a workers' compensation claim. Name: Address: Social Security #:______________________________ 1. (Please print SSN legibly in the blank) Is the above named individual receiving Social Security Disability benefits. Yes No (Please answer question 2) (Thank you for your assistance) 2. Please indicate the monthly amount of Social Security Disability benefits including the Medicare deductible and the dates benefits were paid. $__________ Gross monthly Social Security benefit amount $__________ Monthly Medicare premium deduction $__________ Net Monthly Social Security benefit amount Dates:_____________________________ Requested by:_________________________________________________ Claimant's signature Date Prepared by:___________________________________________________ Social Security Representative Date Telephone # (___)___________________ American LegalNet, Inc. www.FormsWorkFlow.com Filing Instructions COLA/Social Security Verification Request VWC Form No. CA51 In order to apply for Cost-of-Living Adjustment, please complete the following steps: 1. Complete the upper portion of the eligibility form to include the claimant's name, accident date, VWC Jurisdiction Claim Number, and Social Security Number. 2. Take the form to the Social Security Administration. A representative of the Social Security Administration must complete Sections 1 and 2. 3. The eligibility form must be signed by a Social Security Representative. 4. The elibibility form must be signed by the Claimant. 5. Return the form to the Virginia Workers' Compensation Commission for Cost-of-Living eigibility determination. Please Note: In the event that Social Security Benefits are not being received, the signature of the Social Security Representative is still required. For questions or assistance completing this form, please contact the Commission toll-free at (1-877) 664-2566 or visit our website at www.workcomp.virginia.gov American LegalNet, Inc. www.FormsWorkFlow.com
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