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Supplemental Agreement To Pay Varying Temporary Partial Benefits Form. This is a Virginia form and can be use in Workers Compensation.
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Tags: Supplemental Agreement To Pay Varying Temporary Partial Benefits, 4G, Virginia Workers Compensation,
Reserved
Supplemental Agreement to Pay
VWC file number
Insurer location
Varying Temporary Partial Benefits
The boxes
Virginia Workers’ Compensation Commission
1000 DMV Drive Richmond VA 23220
to the right
are for the
Insurer code
SEE INSTRUCTIONS ON REVERSE SIDE
use of the
Insurer claim number
insurer
Employer
Name of employer (see Employer’s Accident 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
Varying Temporary Partial
From ________________ through _______________, claimant was paid $____________ per week as temporary partial compensation.
The weekly wage before the injury was $_____________. The weekly wage for this period was $_______________.
From ________________ through _______________, claimant was paid $____________ per week as temporary partial compensation.
The weekly wage before the injury was $_____________. The weekly wage for this period was $_______________.
From ________________ through _______________, claimant was paid $____________ per week as temporary partial compensation.
The weekly wage before the injury was $_____________. The weekly wage for this period was $_______________.
From ________________ through _______________, claimant was paid $____________ per week as temporary partial compensation.
The weekly wage before the injury was $_____________. The weekly wage for this period was $_______________.
From ________________ through _______________, claimant was paid $____________ per week as temporary partial compensation.
The weekly wage before the injury was $_____________. The weekly wage for this period was $_______________.
From ________________ through _______________, claimant was paid $____________ per week as temporary partial compensation.
The weekly wage before the injury was $_____________. The weekly wage for this period was $_______________.
From ________________ through _______________, claimant was paid $____________ per week as temporary partial compensation.
The weekly wage before the injury was $_____________. The weekly wage for this period was $_______________.
From ________________ through _______________, claimant was paid $____________ per week as temporary partial compensation.
The weekly wage before the injury was $_____________. The weekly wage for this period was $_______________.
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
Virginia Workers’ Compensation Act
Date
Supplemental Agreement to Pay
Varying Temporary Partial Benefits
VWC Form No. 4G (1/1/2005)
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FILING INSTRUCTIONS
(Instructions Updated 09/01/07)
Supplemental Agreement to Pay
Varying Temporary Partial Benefits
VWC Form No. 4G
1.
This form is completed whenever additional consecutive periods of temporary partial compensation 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 the periods are not consecutive, a Supplemental Agreement to Pay Benefits (VWC Form
No. 4A), should be filed.
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. 4).
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 Type of Benefit:
Temporary Partial (TP) Disability – Injured employee is partially disabled for work, but is entitled to receive
compensation for a period of temporary partial wage loss, based upon 66 2/3% (.66667) of the difference between
the pre-injury 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.
*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.
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