This form is to be completed by the claim administrator when the injured worker returns to work at the pre-injury wage or is able to return to pre-injury work. Check the appropriate reason for the termination of the Award and provide the return to work date and wage information, if applicable. If the basis for terminating benefits is for reasons other than what is contained on this form, you may need to file an Employer’s Application for Hearing (VWC Form No. 5A) to terminate the outstanding Award. This form may not be modified to meet a specific case, or the form will be rejected.
For the injured worker: Signing this document is NOT a requirement for payment. If you do not agree with the information contained and make modifications, it will be rejected.
The form should be signed by all required parties. 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. The Claims Administrator also has the option to file electronically through the Commission’s WebFile system at http://webfile.workcomp.virginia.gov. To file electronically, the Claims Administrator must have a valid and active WebFile account.
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.