Agreement To Pay Benefits In A Fatal Case Form. This is a Virginia form and can be use in Workers Compensation.
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