ChoicePoint - Form WCVA

Authorization Form For File Review or Release Of Copies
For The State of Virginia
Workers' Compensation Claims File

I hereby authorize ChoicePoint acting as an agent for ___________________________________________ to review and/or receive copies from Virginia Workers' Comp Board of any or all parts of compensation claim files(s). I understand this authorization will include release of information covering both pending and closed cases involving any work related injuries on file.

To be completed by EMPLOYER:


Date of request:___________________________________________

Signature of requester:___________________________________________

Employer's Full Name:___________________________________________

Employer's Street Address:___________________________________________

Employer's City, State and Zip Code:___________________________________________

To be completed by EMPLOYEE:


Employee's Social Security Number:___________________________________________

Employee's Date of Birth:___________________________________________

Employee's Full Name:___________________________________________

Employee's Street Address:___________________________________________

Employee's City, State and Zip Code:___________________________________________

Signature of Employee:___________________________________________

Subscribed and sworn before me, in my presence, this _______ day of _____________________

19____, a Notary Public in and for the state of _________________________________.


                                                _________________________________
                                                 (Signature of Nortary Public)

My Notary Commission expires _______________, _____.

Note: This information is not to be used in a manner which would violate the Americans with Disabilities Act.

ChoicePoint Form-WCVA