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.

Form NameFirst Injury Report
Form Length2 pages
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 # :

















(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.

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Step 1: You can press the orange "Get Form Now" button at the top of the webpage.

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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 n, jure, d Worker I D Number, Employer, s Legal Name Employer, s, I n, jure, d Worker, Name of I n, jure, d Worker I n, jure, d, 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, VW, C Form # 3, and Rev.

Filling out first injury report step 3

Step 3: Click the Done button to save the form. Then it is available for transfer to your gadget.

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

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