Vwc Form No 3 PDF Details

Are you familiar with the Vwc Form No 3? If not, you should be. This form is a critical part of the workers' compensation process in Virginia. In this post, we'll take a closer look at what the Vwc Form No 3 is and what it means for you or your loved one who has been injured on the job. With so much at stake, it's important to understand exactly how this form works and what steps need to be taken in order to ensure that you're getting the best possible outcome from your claim.

You'll find information about the type of form you intend to submit in the table. It can show you the amount of time you will need to finish vwc form no 3, what fields you will need to fill in, and so on.

Form NameVwc Form No 3
Form Length2 pages
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 #:






(If assigned)









Claim Administrator File#:


















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






where accident occurred

Date of injury

Hour of injury
















Date injury or illness reported

If fatal, give date of death

If fatal, give marital status













If fatal, give number of dependent children

















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.









Occupation at time of injury or illness


Date of birth












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




Submitter (name, signature, title)


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.


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.

How to Edit Vwc Form No 3 Online for Free

The vwc form 3 filling out process is hassle-free. Our editor allows you to use any PDF document.

Step 1: Press the orange "Get Form Now" button on this page.

Step 2: So, you are on the document editing page. You may add content, edit present details, highlight particular words or phrases, place crosses or checks, add images, sign the file, erase unwanted fields, etc.

The following areas are what you are going to fill out to get the prepared PDF file.

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

Step 3: Hit the button "Done". Your PDF document can be transferred. You can easily save it to your computer or email it.

Step 4: Make duplicates of the file - it will help you keep away from future worries. And fear not - we cannot display or read your details.

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