Most Requested Forms – Virginia Workers’ Comp Claims

If you have been injured on the job in Virginia, you may need the following forms. These are PDF files.

IWLF Client Application

The Client Application is the form Injured Workers Law Firm requires for all potential new clients to complete prior to their Strategy and Planning Meeting with the attorney. We request this form to be completed and all related documents be provided prior to the appointment so the attorney can review the information as a whole and give an accurate case evaluation to the injured worker based on their particular situation.

Claim Form

The Claim Form is the Commission’s form and this can be used for several different purposes including; requesting a medical Award, requesting lost wages or requesting a Hearing. Be sure you read the cover page where our IWLF attorneys have explained the importance of this form, the proper way to complete and file the form, as well as the steps your case may take once this form is filed.

IWLF Mileage Money Process

The IWLF Mileage Money Process will provide injured workers with the forms and instructions they need to request a mileage reimbursement from the insurance company for travel to and from medical appointments related to their work place injury. Please remember that the mileage reimbursement will only apply to medical appointments that the insurance carrier has approved.

IWLF Co-Pay Reimbursement Process

The Co-Pay Reimbursement Form is the form injured workers can use to request reimbursement for co-pays, medications and medical supplies (like a knee brace) that the insurance company did not immediately cover. Please remember that these reimbursements will only apply to expenses that the doctor has requested in writing for injuries that have been accepted by the insurance company.

IWLF Steps for Dealing with a Nurse Case Manager

Dealing with a Nurse Case Manager can be tricky and injured workers need to know what their rights are when a case manager demands to be present at their doctor’s appointment. Review this information before a Nurse Case Manager attends any of your doctor’s appointments.

Cost of Living Form

The Cost of Living Form is the form injured workers can use to request their annual Cost of Living increase. This form needs to be completed by the injured worker, signed by a representative from the Social Security Administration and then returned to the injured workers attorney (or to the Commission directly if the injured worker does not have an attorney). The proper time to file the Cost of Living request will depend on the date of your injury and if you are under an Award for lost wages, so make sure you are within the proper time frame to file this request before you pay the Social Security Administration for completing your form!

IWLF Permanent Partial Disability Handout

This handout has been provided by the attorneys here at IWLF to give injured workers a better understanding of what Permanent Partial Disability is and how it is determined. There is also a chart in the back of our book “The Ultimate Guide to Workers’ Compensation in Virginia”, that injured workers will find helpful to look at when reviewing this handout.

IWLF Deposition Handout

This handout has been crafted by the attorneys here at IWLF to help injured workers prepare for an upcoming Deposition. The Deposition is an integral part of your claim and needs to be handled with utmost care! Review this document (several times if necessary) and be educated and prepared so you can have the best possible Deposition to support your case.

IWLF Functional Capacity Handout

The Functional Capacity Exam is scary for many injured workers and often times it can be a turning point in an injured workers’ claim. The attorneys here at IWLF understand this and have compiled this information for injured workers so they can have a clearer understanding of what will take place during the exam and be prepared for the examination and the process that follows. We want to help you make sure that the Functional Capacity Exam is a true reflection of your abilities.

IWLF Job Search Guidelines and Log

When an injured worker is required to do job searching as part of their claim, there are several steps that need to be followed to ensure the job searches are a reflection of a “good faith” effort. Too often, the insurance company finds that an injured worker has failed to do a satisfactory job search effort and refuse to pay wages because of this. Don’t let this happen to you! Use the Job Search Guidelines and tracking Log that our IWLF attorney’s have created to help injured workers avoid this denial of wages.

IWLF Medicare Set-Aside Toolkit

The IWLF Medicare Set-Aside Toolkit is a toolkit our attorneys have created for any injured worker who has settled their workers’ compensation claim with a required Medicare Set-Aside Fund (or MSA). This toolkit is designed to prepare the injured worker with everything they need to know about receipt and record tracking of medical expenses and information that needs to be reported to Medicare.