Free Termination of Wage Loss Award - Virginia

Termination of Wage Loss Award
Virginia Workers' Compensation Commission 1000 DMV Drive Richmond Virginia 23220 1-877-664-2566 SEE INSTRUCTIONS ON REVERSE SIDE Injured Worker's Name: Address: City: Home Phone: Date of Injury: State: Work Phone: ( Zip: ) www.vwc.state.va.us Employer's Name: Address: City: Employer's Phone: State: Zip:

Jurisdiction Claim #: Claim Administrator #:

Pre-Injury Average Weekly Wage:

Payment of Compensation pursuant to the open award is terminated for the reason indicated below. (Choose A or B)

A. The Injured Worker returned to work on

(m/d /yyyy)

at a wage equal to or greater than the pre-injury average weekly wage.

B. The Injured Worker was able to return to pre-injury work on

(m/d/yyyy).

(Documentation supporting release must be attached.)

THIS AGREEMENT IS SUBJECT TO VERIFICATION BY THE COMMISSION PURSUANT TO THE VIRGINIA WORKERS' COMPENSATION ACT

Signatures REQUIRED Signing this form indicates the parties agree that the injured worker returned to work at the pre-injury wage or is able to return to preinjury work.

Signature of Injured Worker

Print Name

Date

(m/d/yyyy)

Signature on behalf of the Employer/Insurer

Print Name

Date

(m/d/yyyy)

Print Name and Address of Claim Administrator

Phone Number

Print Name and Address of Injured Worker's Attorney

Phone Number

This form is required by the Virginia Workers' Compensation Commission

VWC Form #46
Rev. 10/08

Termination of Wage Loss Award VWC Form #46 Filing Instructions Claim Administrator or Authorized Representative: 1. This form is to be completed when the Injured Worker returns to work at the pre-injury wage or is able to return to preinjury work. Submit the completed for to the Virginia Workers' Compensation Commission, 1000 DMV Drive, Richmond, VA 23220. 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.

2. 3.

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. If you have any additional disability from work in the future, your claim can be reopened with the following limitations:

* For questions or assistance with completing this form, please contact Customer Assistance at the Commission's toll-free number 877-664-2566.