Vwc Form 45A PDF Details

In the intricate landscape of workers’ compensation in Virginia, the VWC Form No. 45A emerges as a critical tool for reporting minor injuries. Designed for the efficient communication between employers, insurance companies, and the Virginia Workers’ Compensation Commission, this form plays a pivotal role in the administration of workplace injury reports. It specifically caters to injuries that are not severe enough to result in more than seven days of lost time or incur over $1,000 in medical costs, and it certainly does not apply in cases of fatalities, permanent disabilities, or disfigurements. Through the meticulous process of filling out and submitting this form, employers can provide detailed information about each minor injury incident, including the injured employee’s details, the accident date, and relevant costs. The structure of the form not only insists on the accuracy and legibility of the information presented but also delineates procedures for reporting subsequent medical expenses for already reported injuries, thereby streamlining the follow-up process. The guidelines underscore the importance of monthly submissions, the necessity for initial reporting of medical costs however minimal, and offer clarity on circumstances that necessitate different forms of reporting. With provisions for electronic filing and specific instructions for those preferring manual submission, the VWC 45A form embodies a sophisticated blend of regulatory compliance and operational efficiency, ensuring that minor injuries receive the attention they merit within the broader spectrum of workers’ compensation claims.

QuestionAnswer
Form NameVwc Form 45A
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names45A, exceeds, Insurer, DMV

Form Preview Example

Report of Minor Injuries

Submit to:

Virginia Workers’ Compensation Commission

 

 

 

 

 

 

 

 

45 - A

 

 

 

 

 

 

1000 DMV Drive Richmond VA 23220

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SEE INSTRUCTIONS ON THE REVERSE OF THIS FORM.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of insurer or self-insurer

Period covered

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From

 

/

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To

 

/

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Address

 

 

 

Insurer code

 

Insurer location

Date filed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Person

 

 

 

 

 

Phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Payments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: If this accident has been previously reported on Form 45A, place an “X” in the box by the entry.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of employee

Social Security Number

 

 

Date of accident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address of employee

Name and address of employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Tax Identification Number

Monthly medical cost

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of employee

Social Security Number

 

 

Date of accident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address of employee

Name and address of employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Tax Identification Number

Monthly medical cost

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of employee

Social Security Number

 

 

Date of accident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address of employee

Name and address of employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Tax Identification Number

Monthly medical cost

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of employee

Social Security Number

 

 

Date of accident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address of employee

Name and address of employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Tax Identification Number

Monthly medical cost

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of employee

Social Security Number

 

 

Date of accident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address of employee

Name and address of employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Tax Identification Number

Monthly medical cost

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of employee

Social Security Number

 

 

Date of accident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address of employee

Name and address of employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Tax Identification Number

Monthly medical cost

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of employee

Social Security Number

 

 

Date of accident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address of employee

Name and address of employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Tax Identification Number

Monthly medical cost

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Report of Minor Injuries

VWC FORM NO. 45A (REV. 9/1/99)

FILING INSTRUCTIONS

(Instructions Updated 09/01/07)

Report of Minor Injuries

VWC Form No. 45A

1.This form is used to report minor injuries which do not: a) result in lost time of more than seven days; b) involve more than $1,000 in medical costs; or c) involve a fatality, permanent disability, or disfigurement.* The information you provide is used both to report on medical costs and provides proper notification to injured employees of their rights under the Virginia Workers’ Compensation Act.

2.The insurer should provide the information at the top of the form and the Report of Minor Injuries (VWC Form No. 45A) should be submitted to the Commission on a monthly basis.

3.Type or legibly print all information on the form for each employee including, the social security number, accident date and the federal tax identification number for all employers.

4.Place a check in the box to the left of the employee’s name whenever the accident has been previously reported to the Commission as a Minor Injury Claim and additional medical costs were incurred, but the total medical costs have not exceeded $1,000.

5.If this is the initial reporting of a claim, and there has been no medical cost, place a zero ($0) in the box for monthly medical costs. It is not necessary to report zero ($0) medical costs each month after the initial reporting of the injury.

6.Forms: Additional copies of this form are available without cost by writing to the Commission. Address your inquiry to “Forms” at the listed Virginia Workers’ Compensation Commission address. Please note that any alternate versions of the form you develop yourself require prior approval by the Commission.

7.Electronic Filing: The Report of Minor Injuries (VWC Form No. 45A) can be filed electronically through the Commission’s website, www.vwc.state.va.us and selecting “Electronic Filing Services”. If you are interested in the batch processing method, please contact our “Information Systems Department” at (804) 367-2084 or in writing. Please provide a brief description of your current data processing and communication capabilities.

8.For questions or assistance with completing this form, please contact the First Reports Unit at (804) 367-0072 or the Commission’s toll free number (1-877) 664-2566.

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*More specifically, the seven situations in which you should NOT use this form, and should instead file an Employer’s Accident Report are when (1) lost time exceeds seven days, (2) medical expenses exceed $1,000,

(3)compensability is denied, (4) issues are disputed, (5) the 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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It really is simple to complete the pdf with our practical guide! Here is what you need to do:

1. Before anything else, when filling in the selecting, begin with the area that includes the subsequent fields:

form 45a conclusion process clarified (portion 1)

2. Just after filling in the previous section, head on to the next part and enter the necessary particulars in all these blank fields - Address of employee Name of, Address of employee Name of, Address of employee Name of, Social Security Number Name and, Social Security Number Name and, Date of accident, Social Security Number, Date of accident, Name and address of employer, Social Security Number, Date of accident, Name and address of employer, Social Security Number Name and, and Date of accident.

Filling in part 2 of form 45a

Always be really mindful when filling out Social Security Number Name and and Name and address of employer, because this is the section where a lot of people make a few mistakes.

3. This stage is going to be straightforward - complete every one of the blanks in Address of employee Name of, Social Security Number Name and, Date of accident, Report of Minor Injuries, and VWC Form No A rev in order to complete this segment.

Find out how to fill in form 45a step 3

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