Form required to be completed by unrepresented claimants settling their workers’ compensation claims that provides information necessary for the Commission to determine whether to approve the settlement.
This form 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 804-823-6957.
- 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.