First Injury Report PDF Details

The first injury report of the season is in, and it's good news for the Pittsburgh Steelers. All players have been cleared to play with no major injuries. This is great news for the team as they head into their Week 1 matchup against the Cleveland Browns. While there are some minor injuries that will need to be monitored, the Steelers are optimistic about their chances this season.

Listed here, you may find a number of specifics of first injury report PDF. You might like to read it before typing in the gaps.

QuestionAnswer
Form NameFirst Injury Report
Form Length2 pages
Fillable?Yes
Fillable fields41
Avg. time to fill out8 min 42 sec
Other namesva first report, commission virginia report, virginia first report of injury form, employer virginia 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 # :

 

 

 

 

 

1-877-664-2566

 

 

 

 

 

 

 

 

 

 

(I f assigned)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SEE I NSTRUCTI ONS ON REVERSE SI DE

 

Claim Administrator File# :

 

 

 

 

 

 

 

 

 

www.vwc.state.va.us

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

a.m.

 

p.m.

 

 

 

 

 

 

 

 

 

Date injury or illness reported

I f fatal, give date of death

 

I f fatal, give marital status

 

 

 

 

 

 

 

 

 

 

 

Single

Divorced

 

 

 

 

 

 

 

I f fatal, give number of dependent children

 

 

 

 

 

 

 

 

 

 

 

 

 

Married

Widowed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

 

 

 

 

 

 

 

 

 

Unknown

 

 

 

Occupation at time of injury or illness

 

Date of birth

 

Sex

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

Female

 

 

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)

 

 

Date

 

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.

Employer

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.

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In order to create the va first report PDF, provide the details for all of the parts:

first injury report gaps to fill in

Make sure you enter the essential information in the I f fatal, Hour of injury I f fatal, Single, Divorced, Married, Widowed, Phone Number, I njured Worker I D Number, Employer’s Legal Name Employer’s, I njured Worker, Name of I njured Worker I njured, Date of birth, Nature and Cause of Accident, Occupation at time of injury or, and Signatures area.

first injury report I f fatal, Hour of injury I f fatal, Single, Divorced, Married, Widowed, Phone Number, I njured Worker I D Number, Employer’s Legal Name Employer’s, I njured Worker, Name of I njured Worker I njured, Date of birth, Nature and Cause of Accident, Occupation at time of injury or, and Signatures fields to insert

The application will request you to put down specific key info to effortlessly complete the segment Occupation at time of injury or, VWC Form # 3, and Rev.

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Step 4: Make sure to prevent possible future misunderstandings by preparing at least a pair of duplicates of the document.

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