Supplemental Agreement To Pay Benefits {4A}

Reserved VWC file number Supplemental Agreement to Pay Benefits (formerly: Supplemental Memorandum of Agreement) The boxes Insurer code Insurer location Compensation CommissionsVirginia Worker to the right 1000 DMV Drive Richmond VA 23220 are for the use of the Insurer claim number SEE INSTRUCTIONS ON REVERSE SIDE insurer Employer Name of employer (see Employers First Report) Address Phone number Federal Tax Identification Number Employee Name of employee Phone number Cause of injury/ illness Address Date of birth Nature of injury/ illness(incl. body parts) Social security number City or county where injury/illness occurred: Date of injury or illness List first seven days of incapacity Pre-injury Average Weekly Wage Temporary Total $ shall be paid per week during total incapacity, beginning / / . Temporary Partial $ shall be paid per week during partial incapacity beginning / / , based on a current weekly wage of $ , compared to a pre -injury average weekly wage of $ . Permanent Partial $ sh all be paid per week for a period of weeks beginning / / , based on % loss (or loss of use) of the , payable . (body part) (payment interval) Employer Print Name Phone Date ( ) / / Signature of Employee, guardian, or committee Print Name Phone Date ( ) / / Insurer or authorized representative (signature of processor) Print Name Phone Date ( ) / / Name of Insurer (This space reserved for Commission use) Fee Name and address of employees attorney (if represented) Approved by Date This report is required by the Virginia Workers Compensation Act Supplemental Agreement to Pay Benefits VWC Form No. 4A (rev. 9/1/99) <<<<<<<<<********>>>>>>>>>>>>> 2 INSTRUCTIONS Supplemental Agreement to Pay Benefits (formerly Supplemental Memorandum of Agreement) VWC Form No. 4A 1. Fill out this form whenever additional periods of compensation occur for an accident or illness for which an initial Agreement to Pay Benefits has already been submitted. Submit the form to the Virginia Workers Compensation Commission, 1000 DMV Drive, Richmond VA 23220. 2. The signatures of the employee and a representative of the employer or insurer (including the insurers name) are required. If these signatures are missing, this form will be returned. 3. The information at the top right of the form should be provided by the insurer. Please note that the insurer code refers to the five-digit number assigned by NCCI. Self-insured employers are assigned a similar five-digit number by the Virginia Workers Compensation Commission. 4. When completing this form, please be sure to provide a brief description of how the injury or illness occurred in the Cause of injury/illness box, and to indicate all parts of the body affected in the Nature of injury/illness box. 5. Additional copies of this form are available without cost by writing to the Commission. Please note that color coding of the forms greatly increases the Commissions efficiency in processing claims, and that any alternative versions of the form you develop yourself require prior approval by the Commission. Write to Forms at the listed Virginia Workers Compensation Commission address.