This form is to be completed by the claim administrator whenever a claim has been accepted as compensable and the injured worker is entitled to an award. This Award Agreement provides the basis for the award of compensation and contains sufficient information to establish the essential elements of a compensable claim. For subsequent periods of compensation benefits, this form should be used each time the injured worker’s wage loss period and compensation rate differ. For subsequent periods of temporary partial disability, box 1 should be used, and box 2 should only be used for averaged periods of wage loss.
The form should be signed by all required parties and may be filed with the Commission in the following ways:
- ONLINE: WebFile users may upload this form through their account. Click here to learn more about WebFile.
- FAX: Fax the complete form to 804-823-6956.
- MAIL: Mail the completed form to 333 E. Franklin St., Richmond, VA 23219.
- IN PERSON: Bring the completed form to any of our VWC Office Locations.
For questions, please contact the Commission toll-free at 1-877-664-2566 or by email at Questions@workcomp.virginia.gov.