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 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.