Free First Report of Injury - Virginia

First Report of Injury
Virginia Workers' Compensation Commission 1000 DMV Drive Richmond Virginia 23220 1-877-664-2566 SEE INSTRUCTIONS ON REVERSE SIDE Employer Employer's Legal Name Employer's Mailing Address www.vwc.state.va.us Reason for filing: VWC Jurisdiction Claim #: (If assigned) Claim Administrator File#:

Federal Employer Identification Number (FEIN)

Name/FEIN of Entity on Policy Name and Address of Insurer or Self-Insurer for this Claim

Nature of Business Policy Number

Time and Place of Accident Date of injury Location where accident occurred

Hour of injury a.m. p.m.

Date injury or illness reported

If fatal, give date of death If fatal, give number of dependent children

If fatal, give marital status Single Married Divorced Widowed

Injured Worker Name of Injured Worker Injured Worker's mailing address

Phone Number

Injured Worker ID Number Type of ID Social Security No. Green Card Unknown Employment Visa Passport No.

Occupation at time of injury or illness Nature and Cause of Accident Machine, tool, or object causing injury or illness Describe fully how injury or illness occurred

Date of birth

Sex Male Female

Describe nature of injury, occupational disease, or illness, including body parts affected Signatures Submitter (name, signature, title) Submitter's Address

Date

Phone number

VWC Form #3
Rev. 10/08

First Report of Injury
Filing Instructions The Virginia Workers' Compensation Act requires that ALL injuries occurring in the course of employment be reported to the Commission pursuant to Va. Code §65.2-900. Employer The employer is responsible for accurately completing all sections of this form when an employee is injured. It should be typed or legibly printed, signed, and dated by the preparer. Send the original form to the claim administrator for the insurance company who provided insurance coverage on the date of the occurrence. The claim administrator will report this information to the Commission. Contact your workers' compensation insurance provider for additional information. Claim Administrator Claim administrators who are EDI enabled will use the information contained on the paper form and submit electronic data to the Commission. Claim administrators who are NOT EDI enabled must immediately file the completed form with the Commission. Please note: EDI is mandatory no later than June 30, 2009, after which time paper reports will no longer be accepted. Until you are in EDI production, mail the completed form to the Virginia Workers' Compensation Commission, 1000 DMV Drive, Richmond, VA 23220. At the top of the form, use a numerical code (1-7) to indicate the reason for filing the form for accidents meeting one of the filing criterion.* If none of the criteria apply, you must still report the accident, but may use either Form 45A or this form to do so. (Leave "reason for filing" blank in such a case.) For questions or assistance in completing the form, please contact the Commission toll-free at 877-6642566.

*Criteria for filing are: (1) lost time exceeds seven days; (2) medical expenses exceed $1,000.00; (3) compensability is denied; (4) issues are disputed; (5) accident resulted in death; (6) permanent disability or disfigurement may be involved; and (7) a specific request is made by the Virginia Workers' Compensation Commission.