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Sample Designation of Medical Records, Exhibits and Deposition References
(Note: This is not an official VWC form or document, and is merely an example of a type of document which has been utilized in the past. It may not be suitable for your situation and no warranty is made regarding its reliability.)
VIRGINIA:
IN THE WORKERS’ COMPENSATION COMMISSION
(Name of Claimant),
Claimant
v.
V.W.C. File No.:
(Name of Employer),
Employer
and
(Name of Insurer),
Insurer.
DESIGNATION OF MEDICAL RECORDS,
EXHIBITS AND DEPOSITION REFERENCES
COME(S) NOW the (Claimant) (Employer and Insurer) and submit(s) the following designation pursuant to Rule 2.2(B)(3) of the Virginia Workers’ Compensation Commission:
A. Medical Reports
Name of Health Care Provider Date of Report
1.
2.
3.
4.
5.
B. Exhibits
Author Exhibit Designation Date of Exhibit
1.
2.
3.
4.
5.
C. Deposition References
Name of Deponent Date of Deposition Page Line
1.
2.
3.
4.
Respectfully submitted,
(Name of Claimant) or
(Name of Employer and (Name of Insurer)By: (Signature of Claimant, Claimant’s Attorney, Employer's Attorney)
(Name of Claimant, Claimant’s Attorney
or Name of Employer/Insurer’s Attorney)
Address
Telephone Number
FAX Number
VSB (Virginia State Bar) No.I hereby certify that a true and exact copy of the foregoing Designation of Medical Records, Exhibits and Deposition References was mailed postage prepaid to (Name of Claimant or Name of Opposing Party’s Attorney), (Address), this (day) day of (month), (year).
(Signature)(Name of Party or Attorney)