First Injury Report PDF Details

In the realm of employment and worker safety, the First Report of Injury form serves as a critical document within the Virginia Workers’ Compensation system. Mandated by the Virginia Workers' Compensation Act to be filed for all workplace injuries, this form initiates the formal process of a claim, documenting the essential details of the incident that occurred within the ambit of employment. The form comprehensively captures data such as the employer’s legal information, the specific circumstances and timing of the accident, and the nature and extent of the injury or illness sustained by the worker. Additionally, it outlines the responsibility of the employer to accurately complete and submit this information, either directly to their insurance provider or, in the absence of electronic data interchange (EDI) capabilities, to the Virginia Workers’ Compensation Commission itself. Key to the form are instructions for both preparing and filing, underscoring the transition towards mandatory electronic submission to streamline the process. This transition not only reflects an administrative pivot towards efficiency but also emphasizes the importance of prompt and accurate reporting in the compensation claims process. The form also serves a dual role as a document that can impact the course of claiming workers' compensation benefits, by providing a formal record of the incident that could influence determinations of compensability, eligibility for benefits, and potentially the resolution of disputes regarding the claim.

Form NameFirst Injury Report
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namescommission virginia report, virginia first injury report, virginia first report of injury, va first injury report

Form Preview Example



First Report of I nj ury






Virginia Workers’ Compensation Commission


Reason for filing:














1000 DMV Drive Richmond Virginia 23220


VWC Jurisdiction Claim # :

















(I f assigned)

















Claim Administrator File# :


































Employer’s Legal Name




Federal Employer I dentification Number (FEI N)














Employer’s Mailing Address




















Name/ FEI N of Entity on Policy




Nature of Business















Name and Address of I nsurer or Self-I nsurer for this Claim

Policy Number


















Time and Place of Accident








Location where accident occurred

Date of injury


Hour of injury


























Date injury or illness reported

I f fatal, give date of death


I f fatal, give marital status





















I f fatal, give number of dependent children






























I nj ured W orker










Name of I njured Worker


Phone Number


I njured Worker I D Number













I njured Worker’s mailing address





Type of I D













Social Security No.



Employment Visa










Green Card



Passport No.














Occupation at time of injury or illness


Date of birth




















Nat ure and Cause of Accident








Machine, tool, or object causing injury or illness














Describe fully how injury or illness occurred













Describe nature of injury, occupational disease, or illness, including body parts affected



















Signat ures











Submitter (name, signature, title)





Phone number

















Submitter’s Address

VW C Form # 3

Rev. 10/ 08

First Report of I nj ury

Filing I nst ruct ions

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.


The employer is responsible for accurately completing all sections of this form when an employee is injured. I t 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 Administ rat or

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.* I f 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 877-664- 2566.

*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.

How to Edit First Injury Report Online for Free

Our main developers worked hard to make the PDF editor we're proud to deliver to you. Our software will let you instantly fill in virginia first injury report and saves your time. You just have to try out this particular instruction.

Step 1: Select the orange "Get Form Now" button on the page.

Step 2: Now you are on the form editing page. You may edit, add information, highlight certain words or phrases, insert crosses or checks, and include images.

For each section, complete the information requested by the program.

writing va first injury report stage 1

Type in the requested information in the area I f fatal give number of dependent, Single, Divorced, Married, Widowed, I njured Worker, Name of I njured Worker, Phone Number, I njured Worker I D Number, I njured Workers mailing address, Type of I D, Occupation at time of injury or, Date of birth, Nature and Cause of Accident, and Machine tool or object causing.

Filling in va first injury report part 2

Inside the section referring to Submitters Address, VWC Form, and Rev, one should write down some required particulars.

va first injury report Submitters Address, VWC Form, and Rev blanks to fill out

Step 3: Hit the "Done" button. Now, you can export your PDF file - download it to your device or forward it through email.

Step 4: Generate around two or three copies of your document to refrain from any sort of possible problems.

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