Form 12a - Agreement For The Settlement Of An Award In A Lump Sum Or Partial Lump Sum Page 2
Download a blank fillable Form 12a - Agreement For The Settlement Of An Award In A Lump Sum Or Partial Lump Sum in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 12a - Agreement For The Settlement Of An Award In A Lump Sum Or Partial Lump Sum with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2FILING INSTRUCTIONS
(Instructions Updated 09/01/07)
Agreement for the Settlement of an Award in a Lump Sum or Partial Lump Sum
VWC Form No. 12A
This form is filed and completed by the employee or dependent(s) when requesting the payment of a
Permanent Partial Disability Award in a Lump Sum or Partial Lump Sum. In order for the Lump Sum
Settlement to be approved the Commission, the Commission must be furnished sufficient information to
determine if it is in the best interest of the employee or dependent(s). The information must include
evidence that the employee’s injuries are stabilized, permanency exists, evidence of the employee’s
capabilities to handle the funds, and a detail plan of how the proceeds will be used or invested. The filing
of this form with the Commission is a requirement under §65.2-522. The original copy of the completed
form is filed with the Virginia Workers’ Compensation Commission, 1000 DMV Drive, Richmond, VA
23220.
Forms: Additional copies of this form are available without cost by writing to the Commission. Address
your inquiries to “forms” at the listed Virginia Workers’ Compensation Commission address or visit our
Website at
For questions or assistance with completing the form, please contact the Claims Examination Department
at our Toll-free number (1-877) 664-2566.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal