Case Information. WCB Case No. [enter claimant’s WCB Case No., e.g., 12345678], date of accident/occupational disease [enter claimant’s date of accident/occupational disease, e.g., 10/01/1990], is established as compensable for injuries to the [enter all sites of injuries for this case, e.g., back]. The average weekly wage is $[enter AWW, e.g., $600.00]. The claimant has been classified with a permanent partial disability (PPD), and payments are continuing at the rate of $[enter CCP rate, e.g., $200.00] per week (CCP rate). WCL § 15(8) liability was previously established at [enter percentage of 15(8) reimbursement, e.g., 100] % reimbursement and the 104/260-week retention period has been satisfied. [repeat this paragraph for all claims included in the agreement and specify apportionment if applicable]
Case Information. WCB Case No. [enter claimant’s WCB Case No.], date of accident/occupational disease [enter claimant’s date of accident/occupational disease], is established as compensable for injuries to the [enter all sites of injuries for this case]. The average weekly wage is $[enter AWW]. The claimant has been classified with a permanent partial disability (PPD), and payments are continuing at the rate of $[enter CCP rate] per week (CCP rate). WCL § 15(8) liability was previously established at [enter percentage of 15
Case Information. WCB Case No. [enter claimant’s WCB Case No.], date of accident/occupational disease [enter claimant’s date of accident/occupational disease], is established as compensable for injuries to the [enter all sites of injuries for this case]. The average weekly wage is $[enter AWW]. The claimant has been classified with a permanent partial disability (PPD), and payments are continuing at the rate of
Case Information. Newport News Circuit Court case information is available free of charge on the Internet and is not governed by the terms of this agreement. Case information is current to the preceding business day and is located at w xx.xxxxxx.xxxxx.xx.xx by selecting Circuit Courts from the Case Information Menu.
Case Information. 1. Name of person on whose behalf this Claimant Fact Sheet is being prepared (first, middle, last):
2. Name of person completing this form:
3. Please state the following for the civil action filed by the Claimant, if any:
a. Case caption:
b. Docket number:
c. Contact information of principal attorney representing the Claimant: Name: Firm: Address: Telephone Number: Fax Number: E-mail Address:
4. If you are completing this document in a derivative capacity (e.g., you filed a loss of consortium claim derived from injuries suffered by a family member), please provide the name of the allegedly injured family member(s):
5. If you are completing this document in a representative capacity (e.g., as a legal guardian, or on behalf of the estate of a deceased person), please complete the following:
a. Your name, including other names you have used or by which you have been known and dates you used those names:
b. Your current address:
c. In what capacity you are representing the individual or estate:
d. If you were appointed as a representative by a court, state the: Court that appointed you: Date of appointment:
e. What is your relationship to the individual you represent:
f. If you represent a decedent’s estate, please state the date and cause of decedent’s death:
Case Information. 1. Name of person on whose behalf this Addendum is being prepared (first, middle, last): 2. Name of person completing this form:
