Vwc Form No 3 PDF Details

In the realm of workers' compensation, the VWC No 3 form emerges as a pivotal document, meticulously designed to streamline the initial reporting process for workplace injuries in Virginia. Mandated by the Virginia Workers’ Compensation Act, this form serves as the First Report of Injury, a crucial step in acknowledging and documenting the occurrence of an injury within the workplace, thereby facilitating a path towards potential compensation for affected employees. It requires comprehensive details about the injured party, including their name, identification, contact information, and specific aspects of the injury, such as its nature, cause, and the body parts affected. Furthermore, it captures essential information about the employer, including the legal name, federal identification number, and the insurance or self-insurance information pertinent to the claim. This form is a testament to the structured approach adopted by the Virginia Workers’ Compensation Commission, ensuring all injuries that occur in the line of employment are reported promptly and accurately, underscoring the importance of adhering to filing instructions and utilizing the designated channels for submission. It notably highlights the transition towards Electronic Data Interchange (EDI) and sets specific criteria for when and how to file this form, signifying a blend of adherence to traditional reporting mechanisms while paving the way for more streamlined, electronic processes.

QuestionAnswer
Form NameVwc Form No 3
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesVWCC, first report of injury virginia, Virginia, DMV

Form Preview Example

First Report of Injury

Virginia Workers’ Compensation Commission

 

 

Reason for filing:

1000 DMV Drive Richmond Virginia 23220

 

 

 

 

 

 

VWC Jurisdiction Claim #:

1-877-664-2566

 

 

 

 

(If assigned)

 

 

 

 

 

 

SEE INSTRUCTIONS ON REVERSE SIDE

www.vwc.state.va.us

Claim Administrator File#:

 

 

 

 

 

 

 

 

 

 

 

Employer

 

 

 

 

Employer’s

Legal Name

 

 

Federal Employer Identification Number (FEIN)

 

 

 

 

 

 

 

Employer’s Mailing Address

Name/FEIN of Entity on Policy

Nature of Business

 

 

Name and Address of Insurer or Self-Insurer 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

If fatal, give date of death

If fatal, give marital status

 

 

 

 

 

 

Single

Divorced

 

 

 

 

If fatal, give number of dependent children

Married

Widowed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Injured Worker

 

 

 

 

 

 

Name of

Injured Worker

 

 

Phone Number

Injured Worker ID Number

 

 

 

 

 

 

 

Injured Worker’s mailing address

 

 

Type of ID

 

 

 

 

 

 

 

Social Security No.

 

Employment Visa

 

 

 

 

 

Green Card

 

Passport No.

 

 

 

 

 

Unknown

 

 

Occupation at time of injury or illness

 

Date of birth

Sex

 

 

 

 

 

 

 

Male

 

Female

Nature 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

Signatures

 

 

Submitter (name, signature, title)

Date

Phone number

Submitter’s Address

VWC Form #3

Rev. 10/08

First Report of Injury

Filing Instructions

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. It 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 Administrator

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.* If 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: Press the orange "Get Form Now" button on this page.

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example of blanks in va wc form 3

Fill in the Date injury or illness reported, If fatal give date of death, If fatal give marital status, If fatal give number of dependent, Single, Divorced, Married, Widowed, Injured Worker, Name of Injured Worker, Phone Number, Injured Worker ID Number, Injured Workers mailing address, Type of ID, and Occupation at time of injury or areas with any content that is required by the application.

step 2 to entering details in va wc form 3

Mention the necessary information in Submitters Address, VWC Form, and Rev part.

Filling out va wc form 3 stage 3

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