Employers Application For Hearing {5A}

Employer222s Application for HearingSEE SPECIAL INSTRUCTIONS ON THE REVERSE SIDE JCN Date of Accident Virginia Workers222 Compensation Commission Employee Address City/State/Zip The Commission is requested to suspend benefits for the following reason(s) [attach supporting documentation]: The employee returned to pre-injury work on . The employee was released to return to pre-injury work on per Dr. 264 s report dated . The employee returned to light-duty work on at an average weekly wage of $ . The employee222s current disability is unrelated to the industrial accident noted in Dr. 264 s report(s) dated . The employee failed to report to an employer-requested medical examination with Dr. on . The employee refused selective employment within the employee222s physical capacity at on . The employee failed to cooperate with vocational rehabilitation efforts (documentation must be attached). The employee has refused medical treatment offered by Dr. as noted in the medical report dated . Other Request: Termination/suspension of the outstanding award Change of an outstanding award for temporary total to temporary partial Credit Other Compensation was paid through at the rate of $ per week. I hereby certify under penalty of perjury that the statements in this application are true and correct to the best of my knowledge and that a copy of this application , INCLUDING INSTRUCTIONS ON THE REVERSE SIDE, and all attached supporting documents were sent to the employee at the above address, and to the employee222s attorney (if known) at , and to the Virginia Workers222 Compensation Commission on (date). APPLICANT222S NAME AND TITLE: EMPLOYER/CARRIERSIGNATURE OF APPLICANT: DATE:Registered WebFile Users: type in your signature if submitting through your WebFile account.Notice to the employee: If the Virginia Workers222 Compensation Commission approves this application, your compensation benefits will be suspended. Please refer to the additional instructions on the back of this form. Employer222s Application for Hearing VWC Form No. 5A (rev. 4/01/09) American LegalNet, Inc. www.FormsWorkFlow.com FILING INSTRUCTIONS (Instructions Updated 04/01/09) Employer222s Application for Hearing VWC Form No. 5A Employer Instructions: Complete the Employer222s Application for Hearing (VWC Form No. 5A) on the reverse side of this form. The form must be signed, under penalty of perjury, and sent to the Virginia Workers222 Compensation Commission with supporting documentation. You may submit this form with your electronic signature and supporting documentation via your WebFile account at https://webfile.workcomp.virginia.gov. At the time the application is filed with the Commission, a copy of the application and the supporting documentation must be sent to the employee and to the employee222s attorney, if represented. The employer must send the employee a copy of the 223Employee Instructions224 as shown below. Compensation must be paid in accordance with the Virginia Workers222 Compensation Commission Rule 1.4 (C). If you are relying on Rule 1.4 (F), please indicate that compensation benefits continue to be paid. You will be notified in writing if the Virginia Workers222 Compensation Commission finds it appropriate to suspend compensation benefits or if a determination is made that compensation benefits should not be suspended pending a hearing. Employee Instructions:If you wish to contest the suspension of compensation benefits pending a finaldetermination by a deputy commissioner, you must provide the Virginia Workers222Compensation Commission with a written statement explaining why your compensationbenefits should be continued. This statement and any supporting documentary evidencemust be received at the Commission222s office 15 days from the date of this application. If after examining this application, the attached documentation, and the employee222sresponse, the Virginia Workers222 Compensation Commission determines thatcompensation benefits should not be suspended, you will be notified in writing and yourcompensation benefits will immediately be resumed. If the Virginia Workers222 Compensation Commission finds it is appropriate to suspendbenefits until a final determination can be made by a deputy commissioner, you will benotified either that the case is being referred to the evidentiary docket or that a final decision will be made based on the written record. For questions or assistance with completing the form, please contact the Customer Assistance Department at 1-877-664-2566. American LegalNet, Inc. www.FormsWorkFlow.com