Form Oic Wc 2 – Fill Out and Use This PDF

The OIC-WC-2 form is a critical document used in West Virginia for the reporting of occupational injuries or diseases by employers. It gathers comprehensive details from the initial report of an injury or disease to specific information about the employee, the incident, and the subsequent treatment and wage information. To ensure timely and effective handling of workers' compensation claims, completion of this form is essential for both employers and injured employees. For assistance with filling out the form, click the button below.

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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.

Question	Answer
Form Name	Form Oic Wc 2
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	west virginia form disease, wv occupational disease, oic wc 2, how to west virginia report injury

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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:

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

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

During Disability?

Yes

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:	_______/________/________

How to Edit Form Oic Wc 2 Online for Free

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Filling out section 1 in wv report injury

2. Once the previous section is completed, you need to insert the essential details in If Injury was Fatal Indicate Date, Did Injury Occur on Employers, Yes, No Address or location where injury, What was the Employee Doing when, How did the Injury or Disease, Nature of Injury or Disease cut, Body Parts Injured, Are You Aware of or Do You Suspect, Yes, Do You Have Reason to Question, Yes, No If yes attach a specific, Location of Initial Treatment, and Emergency Room allowing you to go to the third step.

What was the Employee Doing when, How did the Injury or Disease, and Yes in wv report injury

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Signature, Date, and Title in wv report injury

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Form Oic Wc 2 – Fill Out and Use This PDF

Form Oic Wc 2 PDF Details

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