Free Fatal Award Agreement - Virginia

Fatal Award Agreement
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:

Agreement entered into this _____ day of __________, 20_____ by and between the Employer/Claim Administrator and Statutory Dependent(s) for compensation due the dependent(s) of the Employee who sustained an injury on the _____ day of __________, 20_____ as a result of an accident arising out of and in the course of his/her employment which resulted in death on the _____ day of __________, 20_____. The Employer/Claim Administrator agrees to pay and the Statutory Dependent(s) agrees to accept compensation for the benefit of the named dependent(s), in equal proportions, at the rate of $__________ per week, payable every _____ week(s), unless subsequent conditions require a modification; all costs of necessary medical, surgical, and hospital attention and supplies incident to the injury (if any); actual burial expenses not to exceed $10,000.00; and incidental transportation expenses not to exceed $1,000.00. Name Address Date of Birth Relationship to Deceased

HIS AGREEMENT IS SUBJECT TO VERIFICATION AND APPROVAL BY THE COMMISSION Signatures By signing below, we certify that the facts relating to this accident are correct as presented on this form and agree that the dependent(s) shall receive the benefits indicated until suspended in accordance with the provisions of the Virginia Workers' Compensation Act.

Signature of Statutory Dependent

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 Deceased Worker's Attorney

Phone Number

This form is required by the Virginia Workers' Compensation Commission

VWC Form #35
Rev. 10/08

Fatal Award Agreement VWC Form #35 Filing Instructions 1. This form is used in cases that involve a compensable fatality to a worker with dependents. The Fatal Award Agreement provides information relating to the deceased workers' weekly wage and compensation rate, as well as the identity of dependent(s) entitled to receive compensation benefits pursuant to the Virginia Workers' Compensation Act. This Fatal Award Agreement, when executed, must be filed promptly with the Virginia Workers' Compensation Commission, 1000 DMV Drive, Richmond, VA 23220, by the Employer, Claim Administrator, or authorized representative. This form must be accompanied by: 3. Death Certificate Marriage License Birth Certificate

2.

For questions or assistance with completing this form, please contact Customer Assistance using the Commission's toll-free number 1-877-664-2566.