Reserved Supplemental Agreement to Pay Benefits (formerly: Supplemental Memorandum of Agreement) Virginia Workers' Compensation Commission 1000 DMV Drive Richmond VA 23220 SEE INSTRUCTIONS ON REVERSE SIDE The boxes to the right are for the use of the VWC file number Insurer code Insurer location Insurer claim number insurer Employer Name of employer (see Employer’s First Report) Phone number Address Federal Tax Identification Number Employee Name of employee Phone number Cause of injury/ illness Address Date of birth Nature of injury/ illness(incl. body parts) Social security number City or county where injury/illness occurred: Date of injury or illness List first seven days of incapacity Pre-injury Average Weekly Wage Temporary Total $ shall be paid per week during total incapacity, beginning / / . Temporary Partial $ shall be paid per week during partial incapacity beginning a current weekly wage of $ / / , based on , compared to a pre-injury average weekly wage of $ . Permanent Partial $ on shall be paid per week for a period of weeks beginning % loss (or loss of use) of the , payable (body part) / / , based . (payment interval) Employer Print Name Phone Date Print Name ( ) Phone / Date / Signature of Employee, guardian, or committee Print Name ( ) Phone / Date / Insurer or authorized representative (signature of processor) ( ) (This space reserved for Commission use) Fee / / Name of Insurer Name and address of employee’s attorney (if represented) Approved by This report is required by the Virginia Workers’ Compensation Act Date Supplemental Agreement to Pay Benefits VWC Form No. 4A (rev. 9/1/99) American LegalNet, Inc. www.FormsWorkflow.com FILING INSTRUCTIONS (Instructions Updated 09/01/07) Supplemental Agreement to Pay Benefits VWC Form No. 4A 1. This form is completed whenever additional periods of disability occur for an accident or illness for which an initial Agreement to Pay Benefits has already been submitted to the Commission. Submit the completed form to the Virginia Workers’ Compensation Commission, 1000 DMV Drive, Richmond , VA 23220. Note: If additional consecutive periods of temporary partial disability occur, a Supplemental Agreement to Pay Varying Temporary Partial Benefits (VWC Form No. 4G) may be filed in place of this form 2. For subsequent periods of compensation benefits, a Supplemental Agreement to Pay Benefits (VWC Form No. 4A) or a Supplemental Agreement to Pay Varying Temporary Partial Benefits (VWC Form No. 4G) must be filed. 3. The information at the top right of the form should be provided by the insurer. Please note that the insurer code refers to the five-digit numeric code assigned by The National Counsel on Compensation Insurance (NCCI). Selfinsured employers are assigned a similar five-digit code number by the Virginia Workers’ Compensation Commission. 4. Incomplete or illegible forms will either be returned to the insurer for proper completion or they will be rejected. 5. When filling out this form, please be sure to provide a brief description of how the accident or illness occurred in the “Cause of Accident” box. Please indicate all parts of the body affected and which are accepted, in the “Nature of Injury” box. 6. Note that compensation is paid beginning with the eighth (8th) day of disability resulting from a work related accident or illness. If the disability period exceeds more than 21 days, then compensation is owed retroactively for the first seven (7) days of disability. The first seven (7) days of disability includes all days or parts of days when the injured employee was unable to earn a full day’s wages, or was not paid a full day’s wages, due to the injury. These dates should be the same as reflected on the Agreement to Pay Benefits (VWC Form No. AW4). 7. When an employee receives full wages during disability, these days are to be counted towards the waiting period and any subsequent days of disability. Agreement forms need to be completed in their entirety, giving dates and amounts the employee would have been entitled to receive in compensation benefits covering all periods of disability. 8. Definition of Types of Benefits: Temporary Total (TT) Disability – Injured employee is totally disabled for work, and is entitled to receive compensation for a period of total wage loss, based upon 66 2/3% (.66667) of the pre-injury average weekly wage.* Temporary Partial (TP) Disability – Injured employee is partially disabled for work, but is entitled to receive compensation for a period of partial wage loss, based upon 66 2/3% (.66667) of the difference between the preinjury average weekly wage and the post (or current) average weekly wage.* Forms received without specific dollar amounts or those that reflect the word “Various” will be rejected. Permanent Partial (PP) Disability – Injured employee is entitled to receive compensation based upon the loss of use or the loss of a ratable body member, based upon 66 2/3% (.66667) of the pre-injury average weekly wage for a specified number of weeks, pursuant to Va. Code §65.2-503. Please attach a copy, to the agreement form, of the doctor’s report or the amputation chart that supports the permanency rating.* *Compensation rate is subject to yearly maximum and minimum allowances. *All wage information and compensation rate(s) reflected on the form(s) should be based on weekly figures. *The previously established average weekly wage should be used when completing this form. 9. The signatures of the employee and a representative of the employer or insurer (including the insurer’s name and address) are required. If these signatures are missing, this form will be returned. 10. Forms: Additional copies of this form are available without cost by writing to the Commission. This form is also available on the Commission’s Website, at www.vwc.state.va.us. Please note that color coding of the forms greatly increases the Commission’s efficiency in processing claims, and that any alternative versions of the form you develop yourself require prior approval by the Commission. Address your inquiries to “Forms” at the listed Virginia Workers’ Compensation Commission address. 11. For questions or assistance with completing this form, please contact the Awards Unit using the Commission’s tollfree number at (1-877) 664-2566. American LegalNet, Inc. www.FormsWorkflow.com