This form is to be completed by the claim administrator whenever a claim resulted in the death of the injured worker and the claim has been accepted as compensable. The injured worker’s eligible dependents are entitled to an award of benefits, including all costs of necessary medical, surgical, and hospital attention and supplies (if any); actual burial expenses not to exceed $10,000.00; and incidental transportation expenses not to exceed $1,000.00. The Fatal Award Agreement provides the basis for the award of compensation and contains sufficient information to establish the essential elements of a compensable claim. Copies of the Death Certificate, Birth Certificate for all dependents and Marriage Certificate should be submitted along with the Fatal Award Agreement for approval. Please note, if the injured worker was entitled to benefits for lost time prior to the date of death, an Award Agreement must be filed for the appropriate wage loss benefits.
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.