Supplemental Agreement To Pay Varying Temporary Partial Benefits {4G}

Supplemental Agreement to Pay Varying Temporary Partial Benefits Virginia Workers' Compensation Commission 1000 DMV Drive Richmond VA 23220 The boxes to the right are for the use of the insurer Reserved VWC file number Insurer code Insurer claim number Insurer location SEE INSTRUCTIONS ON REVERSE SIDE Employer Name of employer (see Employer's Accident Report) Phone number Federal Tax Identification Number Address Employee Name of employee Address Phone number Date of birth Social security number Date of injury or illness List first seven days of incapacity Pre-injury Average Weekly Wage Cause of injury/ illness Nature of injury/ illness(incl. body parts) City or county where injury/illness occurred: 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 Signature of Employee, guardian, or committee Print Name ( ) Phone / Date / Insurer or authorized representative (signature of processor) Print Name ( ) Phone / Date / Name of Insurer ( (This space reserved for Commission use) Fee ) / / Name and address of employee's attorney (if represented) Approved by Date This report is required by the Virginia Virginia Workers' Compensation Act Supplemental Agreement to Pay Varying Temporary Partial Benefits VWC Form No. 4G (1/1/2005) American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS Supplemental Agreement to Pay Varying Temporary Partial Benefits VWC Form No. 4G 1. Fill out this form 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. Submit the form to the Virginia Workers' Compensation Commission, 1000 DMV Drive, Richmond VA 23220. The signatures of the employee and a representative of the employer or insurer (including the insurer's name) are required. If these signatures are missing, this form will be returned. 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 number assigned by NCCI. Self-insured employers are assigned a similar five-digit number by the Virginia Workers' Compensation Commission. When completing this form, please be sure to provide a brief description of how the injury or illness occurred in the "Cause of injury/illness" box, and to indicate all parts of the body affected in the "Nature of injury/illness' box. Additional copies of this form are available without cost by writing to the Commission. 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. Write to "Forms" at the listed Virginia Workers' Compensation Commission address. 2. 3. 4. 5. American LegalNet, Inc. www.USCourtForms.com