Quick Reference Guide

VirginiaWorkers’ Compensation Commission Claims Services Reference Material

Subrogation Lien Recovery Checklist Injured Worker:

Claim Number:

JCN:

In order for the Commission to determine the effect of the third party settlement on the workers’ compensation case, it will be necessary to provide the following information:

Date of the third party settlement

$ $ $ $ $

Total amount of the third party settlement Total amount of the carrier’s lien

Total amount that the carrier recovered from the lien Total amount of the third party settlement attorney costs Total amount of the third party settlement attorney fees

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