Now you are ready to complete the “Request for Benefits” section and formally request that your injuries and your benefits be recognized by the Virginia Workers Compensation Commission and protected by way of an Award Order.
This section also states “I need assistance obtaining the following benefits. If the benefits are denied, this form will serve as a hearing request”. This means that if the workers compensation insurance carrier does not voluntarily agree to give you an Award, the Commission will then step in and set up a formal hearing for you.
In this section, you will want to check all of the boxes for items that apply to you. Here is a brief explanation of each benefit listed on the Claim for Benefits form:
- Lifetime Medical Benefits
- Payment for medical treatment/expenses for the injury or occupational disease, now and in the future.
- Wage Loss Replacement (Temporary Total Disability – Completely out of work)
- This is to request workers compensation pay for periods the doctor has you completely out of work (with an out-of-work note). You can put the start and end dates listed on your doctor’s note, if you are out of work and don’t know when the doctor plans to return you to work, you could also put “to present” or “continuing” in lieu of ending date.
- Wage Loss Replacement (Temporary Partial Disability – Partially out of work/light duty)
- This is to request workers compensation pay for periods the doctor has you on restricted duty (per a valid doctor’s note) and you are making less money because of it. For example, if the doctor limits the number of hours you can work due to your injury or if your employer is paying you less while you are under the doctor’s work limitation.
- Compensation for Permanent Loss (Permanent Partial Disability)
- This section is for when there has been a permanent loss. Check the applicable boxes and remember, you must provide medical documentation to support this, like medical records and reports.
- Payment/reimbursement for the following expenses
- This section is to request payment or reimbursement of medical bills, or out-of-pocket expenses, such as prescription and mileage/transportation. Check the applicable boxes and remember, you must provide documentation of these expenses like bills, receipts, and/or mileage logs.
- Death Benefits
- Payment/reimbursement of funeral/transportation expenses or wage loss replacement for surviving spouse, children, or certain other dependents. Death certificate, Marriage License, and/or Birth Certificate(s) must be provided.
- Basically, any benefits not previously mentioned (vocational rehabilitation, specific medically necessary treatments or procedures, requesting a panel of physicians, etc.).
Once you have completed all of these sections, you can sign, print your name, date your form and get it filed with the Virginia Workers Compensation Commission.
How do I File the Form Once it’s Completed?
This form may be filed with the Virginia Workers’ Compensation Commission in the following ways:
- ONLINE: WebFile users may upload this form through their WebFile account on the VWC website
- FAX: Fax the completed form to 804-823-6956.
- MAIL: Mail the completed form to 333 E. Franklin St., Richmond, VA 23219.
- IN PERSON: Bring the completed form to any of the VWC Office Locations.
The Award Order process is extremely important, so important in fact that the insurance companies usually won’t even tell you about it because they would prefer you not to know how to protect your rights!
If you have any questions about filling out your Claim for Benefits form or the process of obtaining an Award Order, please call my office and speak to my experienced legal team for free! 804-755-7755
About the Author: Michele Lewane
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.