First Injury Report – Fill Out and Use This PDF

First Injury Report is a helpful app for those who work in the medical field. It provides up to date information about injuries and treatments, making it easy to stay informed.

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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.

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Question	Answer
Form Name	First Injury Report
Form Length	2 pages
Fillable?	Yes
Fillable fields	41
Avg. time to fill out	8 min 42 sec
Other names	va first report, commission virginia report, virginia first report of injury form, employer virginia report

12

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.

How to Edit First Injury Report Online for Free

We found the best website developers to develop this PDF editor. Our application will permit you to create the va first report file without difficulty and won't consume too much of your time. This straightforward guide will let you get going.

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

Step 2: At the moment you're on the file editing page. You can modify and add text to the document, highlight specified content, cross or check particular words, add images, sign it, delete unnecessary fields, or remove them altogether.

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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