Fatal Award Agreement {35}

This form is required by the Virginia Workers222 Compensation Commission VWC Form #35 Rev. 10/08 Fatal Aw ard Agreement Virginia Workers222 Compensation Commission 333 E. Franklin St., Richmond, Virginia 23219 1-877-664-2566 SEE INSTRUCTIONS ON REVERSE SIDE www.vwc.state.va.us Jurisdiction Claim #: Claim Administrator #: Injured Worker 222s Name: Address: City: State: Zip: Home Phone: Work Phone: ( ) - Employer's Name: Address: City: State: Zip: Employer222s Phone: Date of Injury : Pre - Injury Average Weekly Wage: Agreement entered into this day of , 20 by and between the Employer/Claim Administrator and Statutory Dependent(s) for compensation due the dependent(s) of the Employee who sustained an injury on the day of , 20 as a result of an accident arising out of and in the course of his/her employment which resulted in death on the day of , 20 . The Employer/Claim Administrator agrees to pay and the Statutory Dependent(s) agrees to accept compensation for the benefit of the named dependent(s), in equal proportions, at the rate of $ per week, payable every week(s), unless subsequent conditions require a modification; all costs of necessary medical, surgical, and hospital attention and supplies incident to the injury (if any); actual burial expenses not to exceed $10,000.00; and incidental transportation expenses not to exceed $1,000.00. Name Address Date of Birth Relationship to Deceased THIS AGREEMENT IS SUBJECT TO VERIFICATION AND APPROVAL BY THE COMMISSION Signatures By signing below, we certify that the facts relating to this accident are correct as presented on this form and agree that the dependent(s) shall receive the benefits indicated until suspended in accordance with the provisions of the Virginia Workers222 Compensation Act. Signature of Statutory Dependent 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 Deceased Worker222s Attorney Phone Number American LegalNet, Inc. www.FormsWorkFlow.com Fatal Award Agreement VWC Form #35 Filing Instructions 1. This form is used in cases that involve a compensable fatality to a worker with dependents. The Fatal Award Agreement provides information relating to the deceased workers222 weekly wage and compensation rate, as well as the identity of dependent(s) entitled to receive compensation benefits pursuant to the Virginia Workers222 Compensation Act. This Fatal Award Agreement, when executed, must be filed promptly with the Virginia Workers222 Compensation Commission, 333 E. Franklin St., Richmond, Virginia 23219, by the Employer, Claim Administrator, or authorized representative. 2. This form must be accompanied by: - Death Certificate - Marriage License - Birth Certificate 3. For questions or assistance with completing this form, please contact Customer Assistance using the Commission222s toll-free number 1-877-664-2566. American LegalNet, Inc. www.FormsWorkFlow.com