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. This form may be filed by mail or in-person at 333 E. Franklin St., Richmond, VA 23219. This form may also be filed by fax 804-823-6956. 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.