The Virginia VWC Employer’s Application for Hearing (VWC Form No. 5A) is the form a self-insured employer, insurer, or claims administrator files with the Virginia Workers’ Compensation Commission to suspend, terminate, or change an injured worker’s open Award of compensation based on a change in condition. If you pay benefits under an existing Award and the worker returns to work, recovers, or refuses light duty, this is the form that lets you stop those payments the legal way.
Getting this form wrong is costly. File late, skip the supporting medical records, or forget to mail a copy to the employee, and the Commission can reject the application, force you to keep paying benefits, and add penalties on top. The current version is VWC Form No. 5A (rev. 11/21), with filing instructions updated 10/21, so confirm those dates on your copy before you start.
Here is what you will learn in this guide:
- 📋 What Form 5A is, who must file it, and the exact statute and rules behind it
- 🗂️ Every document and detail you need to gather before you open the form
- ✍️ A line-by-line walkthrough of each box, with sample entries and the consequence of each mistake
- 👥 Three real filled-out scenarios followed start to finish by named filers
- ⚖️ How to file through WebFile, fax, mail, or in person, plus what happens after you file
What the Form Is and Who Must File It
Form 5A is the official request an employer side files to ask the Commission to suspend or terminate compensation an injured worker is receiving under an open Award. When a worker is under an ongoing Award, payments do not simply stop on their own. You must file an application with proof, and the Virginia Workers’ Compensation Commission decides whether the suspension is allowed.
The people who file this form are the self-insured employer, the insurer, the claim administrator, or their legal counsel. An injured worker does not use this form. A worker who wants a hearing files a Claim for Benefits instead. So if you are an employee reading this, know that Form 5A is the document filed against your benefits, and you have a right to respond.
The statute behind the form is the Virginia Workers’ Compensation Act, found in Virginia Code Section 65.2. The procedure is governed by Commission Rule 1.4, which controls how and when benefits may be suspended after an application is filed.
The deadline that matters most is built into the filing itself. Once the application is filed, the employee has 15 days from the date of the application to send the Commission a written statement contesting the suspension. The consequence of ignoring the form’s requirements is direct: the employer may be ordered to pay additional compensation, plus penalties and other sanctions.
One revealing statistic shows why care matters here. Virginia processes tens of thousands of workers’ compensation claims each year through the Commission, and a single defective application, such as one missing the proof of service to the employee, can be bounced back and reset the entire suspension timeline. That delay means weeks of extra benefit payments the employer hoped to stop.
Before You Start: Documents and Information You Need
Gather everything before you open Form 5A. A blank box or missing attachment is the top reason applications get held or rejected. Build this packet first so you can fill the form in one sitting.
- The Jurisdiction Claim Number (JCN). This ties the form to the existing claim file, and a wrong or missing JCN can route your application to the wrong case or cause a processing delay.
- The date of accident. The Commission cross-checks this against the open Award, and a mismatch raises a red flag that slows review.
- The employee’s full legal name and current mailing address. You must mail the employee a copy, so a bad address breaks the required service and can void the filing.
- The employee’s attorney’s name and address, if represented. Skipping this when the worker has counsel is a service failure that can delay or defeat the application.
- The supporting medical report or return-to-work documentation. Every suspension reason must be backed by attached proof, and an application with no documentation is routinely rejected.
- The exact date of the triggering event. This is the day the worker returned to work, was released, refused selective employment, or missed an exam, and a vague or missing date weakens the whole request.
- The compensation rate and the through-date. You must certify the weekly rate and the last date paid, because Rule 1.4(C) governs how far payments must continue.
- The applicant’s name, title, and employer or carrier name. The certification is signed under penalty of perjury, so the signer’s identity must be accurate.
If any single item is missing, stop and find it. The form moves as a complete packet, and the Commission treats a partial filing as no filing for timing purposes.
Where to Get the Form and How to Access It
The official form lives on the Commission’s website. Download the current PDF directly from the Employer’s Application for Hearing page, which always hosts VWC Form No. 5A (rev. 11/21). Do not pull a copy from a random third-party site, because outdated versions float around the internet and an obsolete form can be returned.
Registered users also reach the form through the Commission’s online portal. Log in to your WebFile account to complete, electronically sign, and submit the form along with attachments in one place. WebFile is the fastest channel and gives you a timestamped record of filing.
The full form is two pages. The front page is the application you complete. The reverse side holds the Filing Instructions, Employer Instructions, and Employee Instructions, and you are required to send the employee that reverse-side instruction sheet, not just the front page.
If you have no lawyer and need help understanding the process, the Commission’s Ombuds Department answers questions at 833-448-1681 or ombuds@workcomp.virginia.gov. They cannot give legal advice, but the conversation stays confidential.
Step-by-Step: How to Fill Out VWC Form No. 5A Line by Line
Work through the form top to bottom. Use the exact box names printed on the form, attach proof for every reason you check, and keep your entries clean. The sample entries below are italicized so you can tell what gets written on the form apart from the instructions.
1. JCN (Jurisdiction Claim Number)
This box asks for the unique number the Commission already assigned to the worker’s claim. Enter the JCN exactly as it appears on prior Commission correspondence or in your WebFile case file, with no extra spaces. For example, claims adjuster Renee Carter enters JCN VA00001234567 pulled straight from the open Award letter.
What if you cannot find the JCN because the claim is older? Search the employee’s name in WebFile or call the Commission at 1-877-664-2566 to confirm it before filing. The common mistake here is guessing or transposing digits, and a wrong JCN can attach your application to the wrong worker’s file and stall the suspension. A frequent misconception is that the JCN and the claim number from your internal system are the same; they often are not, so always use the Commission’s JCN.
2. Date of Accident
This box asks for the date the work injury happened. Write it in month-day-year format, such as 03/14/2024, matching the date already on record for the open Award. Adjuster Renee Carter confirms the accident date against the First Report of Injury before she types it.
What if the claim involves an occupational disease with no single accident date? Use the date of communication or diagnosis that the Commission has on file for that claim. The common mistake is entering the date the worker last worked instead of the injury date, which causes a mismatch that flags the file for manual review. Many filers wrongly believe any close date will do, but the Commission matches this field against the Award, so it must be exact.
3. Employee, Address, and City/State/Zip
These boxes ask for the injured worker’s full legal name and current mailing address. Enter the name as it appears on Commission records, then the complete street address, city, state, and ZIP, because you must mail the worker a copy here. For example, Daniel Ruiz, 1420 Maple Street, Apt. 3B, Roanoke, VA 24016 goes in these fields.
What if the worker has moved and you only have an old address? Verify the current address before filing, since service to a stale address can void the application. The common mistake is using the address on file from the date of injury rather than the current one, which means the worker never gets the copy and the filing fails. A misconception is that filing with the Commission alone is enough; service on the employee at this exact address is mandatory.
4. Reason(s) to Suspend Benefits (Check and Complete)
This section asks why you want benefits suspended, and you must check the box that fits and fill in its blanks. Each listed reason has its own date or detail field, and you must attach supporting documentation for the one you select. The form lists these reasons word for word.
- The employee returned to pre-injury work on [date].
- The employee was released to return to pre-injury work on [date] per Dr. [name]’s report dated [date].
- The employee returned to light-duty work on [date] at an average weekly wage of $[amount].
- The employee’s current disability is unrelated to the industrial accident noted in Dr. [name]’s report(s) dated [date].
- The employee failed to report to an employer-requested medical examination with Dr. [name] on [date].
- The employee refused selective employment within the employee’s physical capacity at [place] on [date].
- The employee failed to cooperate with vocational rehabilitation efforts (documentation must be attached).
- The employee has refused medical treatment offered by Dr. [name] as noted in the medical report dated [date].
- Other.
To answer, check only the box that matches your evidence and fill every blank in that line. For example, attorney Marcus Webb checks the light-duty box and writes The employee returned to light-duty work on 05/01/2026 at an average weekly wage of $480.00, then attaches the wage records. What if more than one reason applies, such as a release to full duty and a refusal of selective employment? Check each that applies and attach proof for each, since the Commission rules on what you document. The common mistake is checking a reason but attaching no medical report or wage proof, which gets the application rejected outright. A widespread misconception is that issues like a credit, a change in treating physician, or a dispute over the pre-injury average weekly wage justify suspension; they typically do not permit suspension of compensation under Rule 1.4.
5. Request (Type of Relief Sought)
This box asks what outcome you want the Commission to order. Check the option that matches your goal from the listed choices printed on the form.
- Termination/suspension of the outstanding award.
- Change of an outstanding award for temporary total to temporary partial.
- Credit.
- Other.
To answer, mark the one request that fits. For example, when Daniel Ruiz returns to lighter work for less pay, adjuster Renee Carter checks Change of an outstanding award for temporary total to temporary partial because he still earns less than before. What if you want both a suspension and a credit? Check both and explain under “Other” if needed, but attach proof for each. The common mistake is checking “Termination” when the worker is only partially back, which overstates the relief and invites a denial. A misconception is that “termination” and “suspension” mean the same thing; suspension pauses benefits while the case is decided, and termination ends the Award.
6. Compensation Paid Through and Rate
This box asks for the last date you paid compensation and the weekly rate. Enter the through-date and the dollar figure, such as Compensation was paid through 05/01/2026 at the rate of $640.00 per week. Under Rule 1.4(C), the general rule is that compensation must be paid through the date the application is filed, with exceptions for a return to work, refusal of selective employment, or refusal of medical treatment.
What if you are relying on Rule 1.4(F) and benefits continue? Indicate that compensation benefits are still being paid, and the application will be accepted and referred to the hearing docket. The common mistake is cutting off payment before the proper through-date, which violates Rule 1.4 and exposes the employer to penalties. A misconception is that filing the form instantly stops payments; benefits continue until the Commission rules, unless an exception applies.
7. Certification Under Penalty of Perjury
This block asks you to swear the statements are true and that you served the employee. By signing, you certify that the application is true and correct to the best of your knowledge and that a copy of the application, including the instructions on the reverse side, plus all supporting documents, were sent to the employee, to the employee’s attorney if known, and to the Commission on a stated date. Fill in the attorney’s address and the date of filing in the blanks provided.
For example, Marcus Webb writes the employee’s attorney address as Attn: J. Patel, 200 Court St., Suite 4, Roanoke, VA 24011 and dates the certification 06/03/2026. What if the worker has no attorney? Write “none” or leave the attorney blank, but still serve the employee directly. The common mistake is signing without actually mailing the reverse-side instructions to the worker, which is a false certification and can void the filing and expose the signer. A misconception is that this is a routine signature; it is a sworn statement, and a knowingly false certification carries perjury risk.
8. Applicant’s Name, Title, Employer/Carrier, Signature, and Date
This final block identifies who is filing and locks in the signature. Print the applicant’s name and title, the employer or carrier name, then sign and date. Registered users filing through WebFile type in their signature as the electronic signature.
For example, Renee Carter, Senior Claims Adjuster, Commonwealth Mutual Insurance signs and dates the form 06/03/2026, or types her name in WebFile. What if a paralegal prepares the form but an attorney files it? The person certifying must be the one who signs, since the signature carries the perjury oath. The common mistake is leaving the title or carrier name blank, which makes the Commission question who is bound by the certification. A misconception is that any office staffer can sign; the signer must have authority and personal knowledge of the statements.
Three Filled-Out Examples Using Real Scenarios
Below are the three most common fact patterns, each followed by one named filer from start to finish. Each table shows the key entries on Form 5A.
Scenario 1: Worker Returned to Pre-Injury Work (Adjuster Renee Carter)
Daniel Ruiz hurt his back, drew an open Award, and has now returned to his old full-duty job. Adjuster Renee Carter files to terminate the Award.
| Form Section | What Renee Enters |
|---|---|
| JCN | VA00001234567 |
| Date of Accident | 03/14/2024 |
| Employee | Daniel Ruiz |
| Address | 1420 Maple Street, Apt. 3B, Roanoke, VA 24016 |
| Reason checked | The employee returned to pre-injury work on 06/01/2026 |
| Supporting documentation | Employer return-to-work record and wage statement attached |
| Request | Termination/suspension of the outstanding award |
| Compensation paid through | 06/01/2026 at the rate of $640.00 per week |
| Applicant name/title | Renee Carter, Senior Claims Adjuster, Commonwealth Mutual Insurance |
| Date signed | 06/03/2026 |
Scenario 2: Released to Full Duty by Doctor (Adjuster Priya Nair)
Linda Hayes was released by her treating physician to return to her pre-injury job, but she has not gone back. Adjuster Priya Nair files based on the medical release.
| Form Section | What Priya Enters |
|---|---|
| JCN | VA00007654321 |
| Date of Accident | 09/02/2025 |
| Employee | Linda Hayes |
| Address | 88 Oak Lane, Norfolk, VA 23510 |
| Reason checked | The employee was released to return to pre-injury work on 05/20/2026 per Dr. Allen’s report dated 05/18/2026 |
| Supporting documentation | Dr. Allen’s full-duty release note attached |
| Request | Termination/suspension of the outstanding award |
| Compensation paid through | 06/03/2026 at the rate of $710.00 per week |
| Applicant name/title | Priya Nair, Claims Examiner, Tidewater Risk Services |
| Date signed | 06/03/2026 |
Scenario 3: Refusal of Selective Employment (Attorney Marcus Webb)
James Okafor was offered light-duty work within his restrictions but turned it down. Defense attorney Marcus Webb files to suspend benefits for refusal of selective employment.
| Form Section | What Marcus Enters |
|---|---|
| JCN | VA00009998888 |
| Date of Accident | 01/10/2025 |
| Employee | James Okafor |
| Address | 305 Pine Ave., Richmond, VA 23220 |
| Reason checked | The employee refused selective employment within the employee’s physical capacity at Riverside Plant on 05/28/2026 |
| Supporting documentation | Light-duty job offer letter and restriction note attached |
| Request | Termination/suspension of the outstanding award |
| Compensation paid through | 05/28/2026 at the rate of $560.00 per week |
| Applicant name/title | Marcus Webb, Defense Counsel for Employer |
| Date signed | 06/03/2026 |
How to File the Completed Form
The Commission accepts Form 5A through four channels, and you must file a copy on the employee at the same time. Keep proof of filing and proof of service in every case.
- Online (WebFile). Upload the signed form and all attachments through your WebFile account. There is no filing fee, processing is the fastest, and you keep the system’s electronic confirmation as your proof of filing.
- Fax. Fax the complete form with attachments to 804-823-6956. There is no fee; keep your fax transmission confirmation as proof, and expect slower handling than WebFile.
- Mail. Mail the completed form and documents to the Virginia Workers’ Compensation Commission, 333 E. Franklin St., Richmond, VA 23219. There is no fee; send it with tracking or certified mail so you hold a delivery receipt as proof.
- In person. Bring the completed packet to any VWC office location. Ask for a date-stamped copy as your proof of filing.
For all channels, at the time you file you must send the employee, and the employee’s attorney if represented, a copy of the application, the supporting documents, and the reverse-side instructions. For questions, call the Commission toll-free at 1-877-664-2566 or email Questions@workcomp.virginia.gov.
What Happens After You File
Once accepted, the application either suspends benefits pending review or rides on the docket while payments continue, depending on the reason and the rule you rely on. The Commission notifies you in writing whether it finds suspension appropriate or decides benefits should not be suspended pending a hearing.
The employee then has 15 days from the date of the application to send the Commission a written statement explaining why benefits should continue. If the Commission, after reviewing your application, your documentation, and the employee’s response, decides benefits should not be suspended, you are notified in writing and payments resume immediately.
If the Commission finds suspension is appropriate, you are told either that the case is referred to the evidentiary docket for a hearing before a deputy commissioner or that a final decision will be made on the written record. Under Rule 1.4(F), if you certify benefits continue to be paid, the application is accepted and referred to the hearing docket.
A deputy commissioner ultimately decides the dispute. Either side can seek review of that decision by the full Commission, so a clean, well-documented application gives you the strongest footing if the case reaches a hearing.
Mistakes to Avoid When Filling Out the Form
Each error below has a direct consequence. Avoid all of them before you file.
- Filing with no supporting documentation. The application is rejected because every checked reason must be backed by proof.
- Using the wrong or missing JCN. The form may attach to the wrong claim and stall the suspension.
- Entering a date of accident that does not match the Award. The file gets flagged for manual review and slows down.
- Mailing to a stale employee address. Service fails and the entire filing can be voided.
- Forgetting to serve the employee’s attorney. A represented worker’s counsel must get a copy, or the application can be defeated.
- Cutting off payments before the proper through-date. This violates Rule 1.4(C) and exposes the employer to penalties.
- Suspending for a credit, doctor change, or wage dispute. These typically do not permit suspension, so the request is denied.
- Checking “Termination” when the worker is only partially back. The relief is overstated and the application is denied.
- Not sending the reverse-side instructions to the employee. The certification becomes false and the filing can be voided.
- Signing without authority or personal knowledge. The perjury certification is invalid and exposes the signer.
- Leaving the rate or through-date blank. The Commission cannot verify Rule 1.4 compliance and may reject the form.
- Using an outdated version instead of rev. 11/21. An obsolete form can be returned unprocessed.
Do’s and Don’ts
Do:
- Do attach proof for every checked reason, because the Commission rules on what you document.
- Do confirm the current employee address before filing, since service failure voids the application.
- Do serve the employee and their attorney at the same time you file, as the rule requires simultaneous service.
- Do keep your proof of filing and proof of service, because you may need to show the timeline later.
- Do pay compensation through the correct date under Rule 1.4(C), to avoid penalties.
- Do use the current rev. 11/21 form from the official site, so it is not returned.
Don’t:
- Don’t guess the JCN or accident date, because a mismatch stalls the file.
- Don’t suspend for a credit, doctor change, or wage dispute, since those usually fail.
- Don’t stop payments before the through-date, which triggers penalties.
- Don’t sign the certification without personal knowledge, because it carries perjury risk.
- Don’t skip the reverse-side instructions to the employee, which voids the service.
- Don’t file a partial packet, as the Commission treats it as no filing for timing.
Pros and Cons of Filing on Your Own vs. With Help
| Filing Without Counsel | Filing With an Attorney or Adjuster |
|---|---|
| Pro: Saves legal fees on a routine return-to-work suspension. | Pro: Lawyers catch service and documentation defects before filing. |
| Pro: Faster if you already have clean records ready. | Pro: Stronger positioning if the case heads to the evidentiary docket. |
| Pro: Direct control over your own timeline and packet. | Pro: Counsel knows which reasons survive under Rule 1.4. |
| Pro: Ombuds Department offers free, confidential general help. | Pro: Reduces the risk of penalties from an early payment cutoff. |
| Pro: Simple single-reason cases rarely need a hearing. | Pro: Handles the response and hearing if the worker contests. |
| Con: Easy to miss the proof-of-service requirement. | Con: Adds legal cost to a straightforward filing. |
| Con: Mistakes can reset the suspension clock. | Con: May be slower due to internal review steps. |
| Con: No professional read on which reasons hold up. | Con: Less hands-on control for the employer day to day. |
| Con: Higher penalty exposure if Rule 1.4 is misapplied. | Con: Overkill for an undisputed return to pre-injury work. |
| Con: A false certification can fall on you personally. | Con: Coordination time between adjuster and counsel. |
FAQs
Is the Employer’s Application for Hearing the same as a Claim for Benefits?
No. Form 5A is filed by the employer side to suspend benefits, while the Claim for Benefits is filed by the injured worker to request and protect benefits.
Can an injured worker file Form 5A?
No. Form 5A is for the self-insured employer, insurer, claim administrator, or their counsel. Workers requesting a hearing file a Claim for Benefits instead.
Do I have to send the employee a copy of the application?
Yes. At the time of filing, you must send the employee, and their attorney if represented, the application, supporting documents, and the reverse-side instructions.
How long does the employee have to respond?
Yes, there is a set window. The employee has 15 days from the date of the application to send the Commission a written statement contesting the suspension.
Do I write the injury date or the last day worked in the Date of Accident box?
No, never the last day worked. Enter the actual date of accident that matches the open Award on the Commission’s record.
Should I check more than one reason in the suspension section?
Yes, if more than one applies. Check each reason that fits and attach supporting documentation for every box you check.
Does a dispute over the average weekly wage justify suspension?
No. Issues like a credit, a change in treating physician, or a pre-injury average weekly wage dispute typically do not permit suspension under Rule 1.4.
Do I leave the attorney blank if the worker has no lawyer?
Yes. If the employee is not represented, you may leave the attorney address blank or write “none,” but you must still serve the employee directly.
Can I type my signature when filing through WebFile?
Yes. Registered WebFile users type in their signature as the electronic signature when submitting through their account.
Is there a filing fee for Form 5A?
No. The Commission does not charge a fee to file the Employer’s Application for Hearing through WebFile, fax, mail, or in person.
Do payments stop the moment I file the form?
No. Compensation generally continues through the filing date under Rule 1.4(C), with exceptions for return to work, refusal of selective employment, or refusal of medical treatment.
Which version of the form should I use?
Yes, version matters. Use VWC Form No. 5A (rev. 11/21) from the official Commission site, since an outdated form can be returned unprocessed.
What happens if the Commission approves the application?
Yes, benefits can be suspended. You are notified in writing, and the case is referred to the evidentiary docket or decided on the written record.
Can I get help if I have no lawyer?
Yes. The Commission’s Ombuds Department helps at 833-448-1681 or ombuds@workcomp.virginia.gov, though they cannot give legal advice.
Related reading
- How to Fill Out Virginia VWC Award Agreement (w/Examples) + FAQs
- How to Fill Out Virginia VWC Claim for Benefits (w/Examples) + FAQs
- How to Fill Out the Virginia VWC Compromise Settlement Petition + FAQs
- How to Fill Out Virginia VWC Employer’s First Report (w/Examples) + FAQs
- How to Fill Out Virginia VWC Termination of Wage Loss (w/Examples) + FAQs
- Maryland WCC Issues / Request for Hearing Form (H24R) Instructions + FAQs
- How to Fill Out California WCAB DWC-AD 1 (w/Examples) + FAQs