The Vwc form 5 is an important document for any company doing business in Vermont. This form must be filed with the Vermont Secretary of State, and it contains important information about your company. In this blog post, we'll discuss what the Vwc form 5 is and why you need to file it. We'll also provide a link to the Secretary of State's website so you can download the form yourself. Finally, we'll give you a few tips on completing the form properly.
We've gathered some useful information about the vwc form 5. Prior to fill in the form, it's worth checking more about it.
| Question | Answer |
|---|---|
| Form Name | Vwc Form 5 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | claim form, webfile workcomp virginia, vwc form 5, https webfile workcomp virginia gov |
|
|
||||
|
|
|
|||
|
|
|
|||
|
|
|
|||
|
|
|
|||
|
"!#$% |
|
|||
|
|
|
|||
|
|
|
|||
|
|
|
|
||
|
|
|
|||
|
|
|
|||
ïïïKïçêâÅçãéKîáêÖáåá~KÖçî |
#&$% |
|
|
||
!" #$% $&#'!($#& # |
|
|
|||
|
|
|
|||
|
|
|
|||
!(!)!$'#'* +,$ |
|
|
|
||
!./0123/04534 |
|
" 7$$&8$&"(,($#&"9!&% |
|
||
12645./ |
|
7 & $("# %9#& " "$% |
|
||
|
|
|
|
|
|
'(!)% |
|
|
|
||||||||
&% |
|
|
|
|
|
|
|
||||
*% |
|
|
|
+% |
,% |
||||||
|
|
|
|
|
|
|
|
||||
|
|
|
.% |
|
|||||||
/#*0)% |
|
|
|
|
|||||||
&% |
|
|
|
|
|
|
|
|
|||
*% |
|
|
+% |
,% |
|
||||||
|
|
|
|
|
|
|
|
||||
/#*.% |
|
|
|
|
|
||||||
.12!3*'(!%
::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
44444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444 |
|||||||||||||||||||||
|
|
|
|
||||||||||||||||||
1'(!*% |
|
|
|
|
|
|
&5/% |
6 |
|
|
|
||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
718*!*9%444444444444444444444444+444444444444444444 |
|
|
|
|
|
||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
'1#!#% |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
• |
1!#%4444444444444444444444444444444444444444444444444 |
|
|
|||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
• |
*!#1#*% |
|
|
|
|
|
|
|
|
|
|
|
|
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
• |
#*!!:*% |
|
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
':*1##*!&1(!*: |
|||||||||||||||||||||
: ;#.3:#<'=!*1 |
|
|
|
||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
44444444444444444444444444444444444444444 |
44444444444444444444444444444444 |
4444444444444444 |
|||||||||||||||||||
'(!+!8=!9 |
|
.) |
|||||||||||||||||||
::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
!( +, "(# &
$04;<31<;0=/3<4>?
'#1&1#:11*(!*8#!*#*>19??
':!1*(!*1%@%44444444444444A%44444444444444444??
@%44444444444444A%44444444444444444 |
||
'#*#:!1*(!*1%@%44444444444444A%4444444444444444??
@%44444444444444A%4444444444444444 |
|||||
|
|
|
|
|
'#1!!1:*<#1<#!:#*1! ??
'!#:##!1#B#*(!* ??
'=!:11!#B
C4444444444444444444444444444444444444444444444444444444444444444444444444444444
8 <.A#:#*< 9
??&#<D:##< '1*=!1<###E1
|
||
|
|
<$/4
'1*!::**!#*#11:!1
*!(!*1#1*!(!*<*!!1##
*!:1!# /1*! =!1:1<*!!###!:1 .&#
*11*!1
'1*!=!1:11#*!#<#
.311!:#1<:# 2!*:1*!##*1*!*
'1#%
#*!#(!*#!:1#
@##*!#:# '1*!!:# :1*!#:##<*!*=!!::*
1##1 & 6 **:#+111*!*#
#!:#!1!: A!!:!
@ =! # 1< #
##1EFGGEHHIEJHH!:ïïïKïçêâÅçãéKîáêÖáåá~KÖçîKwww.workcomp.virginia.gov www.workcomp.virginia.gov
Benefits Covered under the Virginia Workers’ Compensation Act:
•Lifetime Medical Benefits – Payment for expenses related to the injury or occupational disease. Includes payment/reimbursement of out of pocket medical, prescription and transportation expenses.
•Wage Loss Replacement (Temporary Total/Temporary Partial Disability): Full or partial wage loss replacement for medically authorized disability from work.
•Permanent Partial Disability – Compensation for loss of use of a body part, loss of hearing/vision, amputation, lung disease or bodily disfigurement/scarring.
•Permanent Total Disability – Lifetime wage replacement for loss of both hands, arms, feet, legs, eyes or any two in the same accident, or is paralyzed or disabled from a severe brain injury.
•Death Benefits – In cases where injury results in death, surviving spouse, children, or certain other dependants may be entitled to wage loss replacement benefits and payment of funeral/transportation expenses.
•Other: Mileage reimbursement, Cost of Living Increases, if eligible. (total wage loss and fatal benefits)