Free Claim for Benefits and Request for Hearing - Virginia

Claim Form & Request for Hearing
Virginia Workers' Compensation Commission 1000 DMV Drive Richmond Virginia 23220 1-877-664-2566 SEE INSTRUCTIONS ON REVERSE SIDE www.vwc.state.va.us Jurisdiction Claim #: Claim Administrator #:

Injured Worker's Name: Address: City: Home Phone: Parts of Your Body Injured: State: Work Phone: Zip:

Employer's Name: Address: City: Employer's Phone: State: Zip:

__________________________________________________________________________________________________ __________________________________________________________________________________________________

Date of Injury*:

Average Earnings per week:

$

*in case of disease, give date doctor told you that disease was caused by work

PART A (Claim Form) (All injured workers should complete this section for workers' compensation injuries) I hereby file this claim to protect my rights under the Virginia Workers' Compensation Act for the injury or disease described above. I am not requesting the Commission take any specific action at this time. ________________________________ Injured Worker's signature ______________________________ Print Name ______________ Date

Please sign and return to the Commission. Complete Part B below only if you are requesting a hearing. Part B (Request for Hearing) (You are not required to complete this section--do so only if you are requesting a hearing) I hereby request a hearing from the Commission. I am seeking the following: An Award for medical benefits for my injury (including any treatment already received & paid for) ** I missed work because of my injury on (dates) ____________________________________________________ ** I earned less pay because of my injury on (dates) __________________________________________________** I have a loss of or loss of use of a body part or have disfigurement. ** I have unpaid medical bills relating to my injury. ** Other _______________________________________________________________________________

________________________________ Injured Worker's signature ** Attach medical records or bills.

______________________________ Print Name

______________ Date

If there are any questions regarding this form, please contact the Commission toll-free at 1-877-664-2566.

BARCODE (Form Identifier & JCN)
VWC Form #5
Rev. 10/08

Claim Form & Request for Hearing VWC Form #5 Filing Instructions 1. Even if you have be enpaid by your employer or claim administrator for time missed from work because of your injury or for medical treatment for your injury, you must file a claim with the Virginia Workers' Compensation Commission to protect your right to benefits under Virginia la w. File this Claim Form, with Part A completed, with the Commission as soon as possible. 2. For questions or assistance with completing this form, please contact Customer Assistance using the Commission's toll-free number 877-664-2566. 3. If you are requesting a hearing, you must file medical reports supporting your request with the Commission. If you are requesting a hearing, complete Part B of t his form and submit the medical reports either attached to the form, or as soon as possible. 4. If you are not requesting a hearing at this time, you may do so at a later date, but you should still submit this form with Part A completd. To request a hearing at a later date, please contact the Commission at 877-664-2566 or the Commission's website at www.vwc.state.va.us to obtain another copy of this form. 5. You may obtain copies of your medical records directly from your physician. Please contact the Commission at 877-664-2566 for assistance.