How to Fill Out a Claim for Benefits Form

The step by step guide on filling out your Claim for Benefits form. This will help you  fill out all the right and necessary areas to get your full maximum benefits.
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Video Transcript

In this presentation, we will explain how to fill out a Claim for Benefits form for a workers compensation claim.

Since each case is different, I strongly advise you to have an attorney fill out your Claim for Benefits or, at the very least, review the claim with you so that your benefits are protected.

When you get a Claim for Benefits form, which you can download from our website, or from the Virginia Workers Compensation Commission website, you will see that there are two parts, part A and Part B.

Make sure you fill out part A completely, be sure you include your name and employer’s contact information.

The next most important section is labeled parts of your body injured. Here you list all of your body parts effected by the injury. It is important to list all effected body parts, even the minor injuries, as the insurance company is not legally responsible to cover the cost of the injury if the body part is not listed. When in doubt, listing the body part is the best idea.

In this section, it is your opportunity to give a detailed description on how the injury occurred. Remember, being injured by lifting boxes all day or slipping somehow are not covered injuries, you MUST be specific with a specific time and specific event.

For example, while I was lifting the third bucket of paint to the shelf I felt a sharp pain in my lower back or I slipped and fell because I was not able to see the wet floor since I was carrying a large box.

In this section you need to fill in the date of the injury and your average weekly wage. Make sure that you include overtime and bonuses into your average weekly wage amount.
If you are slightly off on the wage amount don’t worry, a 52 week wage statement will be created from your pay stubs and the weekly wage amount will get adjusted.

If you’re on the insurance adjuster, make sure that your overtime, bonuses and possible shift differentials are added. Also remember, if you have a second similar job, the wages from that work can also be added, so if you are a waitress in two different restaurants you can list all wages. However, if you are a waitress and a cook, those jobs are not similar and do not add to your average weekly wage.

Remember to sign and date the Claim for Benefits form at the end of part A.

In part B, you will specify what it is that you are requesting. Even though the form say optional, we strongly suggest that you fill out this section. At a minimum you want to request lifetime medical benefits, so be sure to check that box.

In the lost wages section you need to add the dates that you have lost a full day of work. If you are still out of work, then you need to list the first date, than add until present and continuing.

If you are only able to work 4 hours each day, then you need to ask for partial lost wages by checking the third box and giving specific dates.

By checking the 4th box, you’re asking for permanent partial disability benefits, which is the permanent loss of use of a body part. This is not something that is normally filled out right away but after a doctor states that you will not be getting any better. At that time, you would need to fill out an additional form requesting permanent partial disability benefits at that time.

You would check box 5 if doctors or medical providers are sending you copies of bills requesting payment.

Box 6 is for requesting death benefits

And “other” would be for requesting specific things, like approval for an MRI or other such items.

Lastly, you need to attach your medical records, any itemized bills and receipts, or your out of work disability slips. If these items are not attached with your request, your claim will be filed and put on hold by the Commission until additional medical records are received.

Filing a claim is a slow process, so if you can help speed things up by supplying all the needed information right from the beginning, there is a better chance of your claim being processed quickly.

Once you have filed your completed claim form with the Virginia Workers Compensation Commission, you will receive a copy of the 20 Day Order request, that is generated by the Commission to the insurance carrier which gives them 20 days to legally either accept or deny the claim. If the claim is denied they will have to give specific reasons why the claim is being denied.

If the claim is accepted, you will have to sign agreement forms sent to you by the insurance company and, once the adjuster is able to submit them to the Commission, the Commission will issue an Award Order and you’ll be protected.

The Injured Workers Law Firm is focused on serving clients with workers’ compensation claims throughout Virginia.For answers to your questions about benefits download our book, The Ultimate Guide to Workers’ Compensation in Virginia or call our office today (804) 755-7755. The Injured Workers’ Law Firm, serving Fredericksburg, Virginia Beach, Manassas, Charlottesville, Fairfax, Hampton Roads and all of Virginia.


About the Author:

The Injured Workers Law Firm is a Richmond, Virginia based firm solely focused on serving clients with workers' compensation claims in Virginia. If you have questions about your benefits or if you would like more information on the Virginia workers’ compensation system, order our book, “The Ultimate Guide to Workers’ Compensation in Virginia” , or call our office today (804) 755-7755.