Form Oic Wc 2 PDF Details

In the landscape of workers' compensation within West Virginia, the Form OIC-WC-2 stands as a critical document, bridging the gap between employers and the regulatory framework governing occupational injuries or diseases. Designed to be filled out with utmost precision, this form serves as the Employers' Report of Occupational Injury or Disease, capturing comprehensive details that span from basic employer and employee information to the intricate specifics of the incident in question. Employers are tasked with filling out various sections, including detailed employer information, comprehensive employee data, and the nuanced particulars of the injury or disease—ranging from the time and location of the occurrence to the nature and extent of the injuries sustained. It also delves into the intricacies of wage and lost time information, crucial for understanding the financial impact of the incident on both the employer and the employee. Beyond its function as a reporting tool, the form serves as a legal document that holds significant weight, especially in light of West Virginia Code §61-3-24e, which outlines severe penalties for the submission of false information, underscoring the importance of accuracy and honesty in these submissions. By meticulously outlining the procedure to report occupational injuries or diseases, Form OIC-WC-2 embodies the procedural cornerstone of workers’ compensation claims in West Virginia, ensuring that both employers and employees navigate the aftermath of workplace incidents with transparency and due diligence.

QuestionAnswer
Form NameForm Oic Wc 2
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswest virginia form disease, wv occupational disease, oic wc 2, how to west virginia report injury

Form Preview Example

Form OIC-WC-2

West Virginia Workers’ Compensation

Employers’ Report of Occupational Injury or Disease

PLEASE PRINT OR TYPE

 

Section I

Employer Information

 

 

 

Insurer:

 

Third-Party Administrator:

 

 

 

 

 

 

 

 

 

Employer’s Name:

Nature of Business:

FEIN:

 

 

 

 

 

 

 

 

Address:

 

 

 

 

City:

State:

Zip:

Telephone: ( ) -

 

 

Section II

 

 

 

 

 

 

 

 

Employee Information

 

 

 

 

 

 

 

Name: (Last):

 

 

 

 

 

(First):

 

 

 

 

 

(M.I.):

 

Occupation/Job Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone: (

)

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

State:

 

 

 

 

 

Zip:

 

Social Security No.:

-

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth:

 

/

 

/

 

 

 

 

6. Sex:

M

 

 

 

 

F

 

Marital Status:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Injured Employee is (check all that apply):

 

Full-Time

Part-Time

 

Volunteer

 

Employee’s Occupation/Job Title:

 

 

 

 

Owner/Partner

 

 

 

Officer

 

 

Retired – Date Retired:

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section III

 

 

 

 

 

 

Information Regarding Injury or Disease

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Injury or Last Exposure:

 

/

 

/

 

 

 

 

 

Time:

a.m.

p.m.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Employer Notified of Injury

 

 

Supervisor to whom Injury or Disease

 

or Disease:

/

/

 

 

 

 

Reported:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If Injury was Fatal, Indicate Date of Death:

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

Did Injury Occur on Employer’s Property?

 

 

Yes

 

No Address or location where injury

occurred:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Witnesses to Injury:

What was the Employee Doing when Injury Occurred (loading truck, walking down stairs, etc.):

How did the Injury or Disease Occur (be specific; include time that employee began work on the date of injury, any equipment, tools, substances or objects connected to the injury; attach additional sheet if necessary):

Nature of Injury or Disease (cut, bruise, strain, etc.):

Body Part(s) Injured:

Are You Aware of, or Do You Suspect, a Prior Injury to this Body Part?

Yes

No

 

 

 

 

 

 

 

 

 

 

Do You Have Reason to Question this Injury?

Yes

No

(If “yes,” attach a specific explanation to this form).

 

 

 

 

 

 

 

 

 

 

 

Location of Initial Treatment:

 

 

Emergency Room?

Yes

No

Hospitalized?

Yes

No

 

Section IV

 

 

 

 

 

 

Wage and Lost Time Information

 

 

 

 

 

 

 

 

 

 

 

Date Hired:

 

/

 

/

 

 

 

Last Day Worked After Occupational Injury or Disease:

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of Work Days Lost:

 

Date of Return to Work:

 

/

/

 

 

Hours Worked per Week:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is Light Duty Available?

 

Yes

No

Wage on Date of Injury: $

 

 

 

 

per

hour

day

week

month

 

 

 

 

 

 

 

 

 

Are Wages Being Paid to Injured Employee

If Employee has Returned to Work, is it Alternative or Modified Work?

Yes

No

 

 

During Disability?

 

 

 

Yes

No

If “yes,” indicate current wage: $

 

 

per

hour

day

week

month

 

 

 

 

 

 

 

 

 

 

 

 

Daily rate of pay on the date of injury: $

and best quarter wages of preceding four quarters $

 

 

 

 

 

 

I certify the statements and answers set forth in this section are true and correct to the best of my knowledge. I am aware the law, specifically West Virginia Code §61-3-24e, provides for severe penalties if I knowingly certify a false report or statement and/or withhold a material fact regarding any information requested. I acknowledge the provisions of the aforementioned code and the severe penalties for knowingly with fraudulent intent aiding or abetting anyone in securing or attempting to secure benefits to which he or she is not entitled.

Print Name:

 

Title:

 

 

 

 

 

Signature:

_____________________________________________

Date:

_______/________/________

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