Informational Letter Where Employee Is Not

Summary

A Form Confidential Informational Letter for an Employee who is NOT Represented by Counsel
To: P&O Department
Virginia Workers’ Compensation Commission
Name of Employee: ______________________________________
Re: Jurisdiction Claim No.: ___________________________________
I submit the following information in order to assist the Virginia Workers’ Compensation Commission in
determining whether to approve the proposed settlement of my pending workers’ compensation claim

I understand that this information will be sealed and held in confidence by the Commission

1. Date and injury of my injury or disease: _____________________________________________
2. Age _____ years
3. Family status: _______________ (married, single, divorced, widowed)

4. Name and ages of all dependents
Name Age Relationship to Employee, i.e., son,
daughter, or spouse
5. Are you current working? (yes or no) (circle one) If yes, please provide the following:
Employer Weekly Wages and Date of Return to Work
6. Please indicate the amount and source of any other income: (If you have no other income sources,
please indicate “none” in the area below.)
Source Amount
7. Are you able to read, write and understand the English language? (yes or no) (circle one)

If you are not literate in English, state the name of the person reading and/or translating and
explaining the settlement papers to you

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Name of Person Address Telephone Number
8. Are you currently receiving medical treatment? (yes or no) (circle one)
Date of last medical treatment ________________________________________________________
(a) Please describe the type of treatment and how often you visit your treating physician:
(b) Identify the doctor(s) in the space below

Name Address Telephone Number
(c) Are there outstanding medical expenses? (yes or no) If yes, please state the name of the
medical provider and the amount due

9. Do you expect future medical expenses related to this injury? (yes or no). (circle one)
If you anticipate future medical expenses, please describe below:
Type of Medical Expenses & Treatment When or How Often Anticipated
10. Do you have any other insurance that will cover your medical expenses after the settlement? (yes
or no) (circle one). Please give the name of the company

_______________________________________
11. What is your intended use of the settlement proceeds? ___________________________________
12. Are you receiving Social Security Disability benefits? (yes or no) (circle one) $_______________
If you are not receiving Social Security Disability benefits, do you intend to apply for such benefits?
(yes or no) (circle one)
13. Are you currently receiving Medicare benefits? (yes or no) (circle one) If yes, for disability or old
age retirement?
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14. Because you are not required to settle your claim, please explain, in your own words in the space
provided below, why you believe the settlement proposal is in your best interest

Please provide the following: (required)
Employee’s Signature: Address: Telephone No. Date:
Please attach additional sheets to supplement your answers to any of the above questions

Please return this completed form to:
P&O DEPARTMENT
Virginia Workers’ Compensation Commission
333 E. Franklin Street
Richmond, VA 23219
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A Form Confidential Informational Letter for an Employee who is NOT Represented by Counsel To: P&O Department Virginia Workers’ Compensation Commission Name of Employee: _____ …

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Frequently Asked Questions

What is the format of a warning letter to an employee?

Here is a basic format for a warning letter to an employee. This letter is to serve as a written warning to you for { behavior } on { date or dates }. This behavior is unacceptable, as outlined in { name of rule or policy, page number } of the employee handbook.

What does it mean when an employer writes a termination letter?

In some cases, the employer or hiring manager writes this letter to different customers and clients to make them aware that the employee who was dealing with them previously will no longer be representing the company. The company should know that some customers might place an order for that employee again.

Can a company send a letter to an employee who is no longer?

Letter Stating Person No Longer Employed Many times, a company receives a parcel or a letter which has been sent to an employee who does not work in that company anymore. In various cases, the company receives an inquiry email from a customer asking about an employee.

Do you know who you are writing to in a letter?

You should know who you are writing to and who would be reading your letter. It will also help you know the details to be provided in the letter. For example, a letter stating person no longer an employee written to the customer of that employee will be different from the one written to the colleague.