American LegalNet, Inc. www.FormsWorkFlow.com FILING INSTRUCTIONS (Instructions Updated 09/01/07) Agreement for the Settlement of an Award in a Lump Sum or Partial Lump Sum VWC Form No. 12A This form is filed and completed by the employee or dependent(s) when requesting the payment of a Permanent Partial Disability Award in a Lump Sum or Partial Lump Sum. In order for the Lump Sum Settlement to be approved the Commission, the Commission must be furnished sufficient information to determine if it is in the best interest of the employee or dependent(s). The information must include evidence that the employee’s injuries are stabilized, permanency exists, evidence of the employee’s capabilities to handle the funds, and a detail plan of how the proceeds will be used or invested. The filing of this form with the Commission is a requirement under §65.2-522. The original copy of the completed form is filed with the Virginia Workers’ Compensation Commission, 1000 DMV Drive, Richmond, VA 23220. Forms: Additional copies of this form are available without cost by writing to the Commission. Address your inquiries to “forms” at the listed Virginia Workers’ Compensation Commission address or visit our Website at www.vwc.state.va.us. For questions or assistance with completing the form, please contact the Claims Examination Department at our Toll-free number (1-877) 664-2566. American LegalNet, Inc. www.FormsWorkFlow.com