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Agreement To Pay Benefits In A Fatal Case Form. This is a Virginia form and can be use in Workers Compensation.
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Tags: Agreement To Pay Benefits In A Fatal Case, 35, Virginia Workers Compensation,
COMMONWEALTH of VIRGINIA
Workers' Compensation Commission
1000 DMV Drive
Richmond, Virginia 23220
FAX: (804) 367-9740
AGREEMENT TO PAY BENEFITS IN A FATAL CASE
VWC File No.
_________________________ Insurer Claim No. ________________________
Name of Insurer __________________________________________________________________
NOTE: This agreement, when executed, shall be filed promptly by the employer or insurance
carrier with the Commission.
Agreement entered into this _____________ day of ____________________________, 20__, by and between
_________________________________________ of ____________________________________________
(Name of Employer)
(Employer’s address)
and _____________________________________ of ____________________________________________
(Name of Principal Dependent)
(Principal Dependent’s address)
for compensation due the dependents of ______________________________, an employee of said Employer
(Name of 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 and which resulted in death on the _______ day of ______________, 20__.
This Agreement is based on the following agreed facts:
Place of Accident ________________________________________________________________________
Cause of Injury or Illness ___________________________________________________________________
Nature of Injury or Illness ___________________________________________________________________
Pre-Injury average weekly wage was $________________________________________________________
That the following was/were totally or partially (circle one) dependent on the deceased employee prior
to the accident:
RELATIONSHIP
NAME
ADDRESS
DATE OF BIRTH
TO DECEASED
Subject to the approval of the Virginia Workers’ Compensation Commission, the Employer agrees to pay and the Principal
Dependent agrees to accept compensation for the benefit of the above-named dependent(s), in equal proportions, at the
rate of $_________.__ per week, payable every __________ week(s) for __________ week(s), unless subsequent
conditions require a modification, and all costs of necessary medical, surgical and hospital attention and supplies incident
to the injury and cost of burial expenses in the sum of $__________.__.
If dependency was partial, the following statements must be completed:
Total monthly or yearly (circle one) amount necessary to support dependents prior to the accident was
$__________.__.
The deceased contributed the sum of $__________.__ for the month or year (circle one) prior to the accident for
the support of said dependent.
Principal Dependent
Print Name
Phone
(
Insurer or authorized representative (signature of processor)
Print Name
Phone
(
Date
)
/
/
Date
/
)
/
Name and address of Insurer
Name and address of attorney (if represented)
Fee
Date
Approved by
/
/
Agreement to Pay Benefits in a Fatal Case
VWC Form No. 35 (rev. 9-1-04)
American LegalNet, Inc.
www.USCourtForms.com
