In cases of fatality the injured worker’s dependent(s) must file a COLA Request Form every year in order to apply for the applicable cost of living adjustments.
The injured worker’s dependent(s) must complete the upper portion of the eligibility form to include the name of the deceased, accident date, Jurisdiction Claim Number and Social Security Number of the deceased. The dependent(s) must have a representative from the Social Security Administration complete Sections 1 and 2. The eligibility form must be signed by a Social Security Representative even if Social Security Survivors Benefits are not being received. The eligibility form should be signed by the injured worker’s dependent(s) and then filed with the Commission.
This form may be filed electronically through the Commission’s WebFile system at http://webfile.workcomp.virginia.gov. To file electronically, the user must have a valid and active WebFile account. This form may be filed by mail or in-person at 1000 DMV Drive, Richmond, Virginia 23220. This form may also be filed by fax (804) 367-6124.
For questions or assistance with completing this form, please contact the Virginia Workers’ Compensation Commission toll free at 1-877-664-2566 or by email at Questions@workcomp.virginia.gov