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.

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

Form Preview Example

 

 

 

Employer’s Accident Report

 

 

 

 

 

 

 

Reason for filing

 

 

 

 

 

VWC file number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(formerly: Employer’s First Report of Accident)

 

The boxes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Virginia Workers’ Compensation Commission

 

to the right

 

Insurer code or PEO Ref. No.

 

 

Insurer location

 

 

 

 

1000 DMV Drive Richmond VA 23220

 

are for the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SEE INSTRUCTIONS ON THE REVERSE OF THIS FORM

 

use of the

 

Insurer claim number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

insurer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

Name of employer (trading as or doing business as, if applicable)

 

2.

 

Federal Tax Identification Number

 

3. Employer’s Case No. (if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Mailing address

 

 

 

 

 

 

 

 

 

 

 

5.

 

Location (if different from mailing address)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Parent corporation /Policy Named Insured

(if applicable) or PEO name

7.

 

Nature of business ( NAICS Code if available)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Name and Address of Insurer or self-insurer for this claim

 

 

 

9.

 

Policy number

 

 

 

 

 

 

 

 

10.

Effective date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time and Place of Accident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

City or county where accident occurred

12. Date of injury

13.

Hour of injury

 

14. Date of incapacity

 

15.

Hour of incapacity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.m.

 

p.m.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13a.

Time began work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.m.

 

p.m.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16.

Was employee paid in full for day of injury?

 

 

17.

Was employee paid in full for day incapacity began?

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

18.

Date injury or illness reported

 

19. Person to whom reported

20.

Name of other witness

 

 

21.

 

If fatal, give date of death

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22.

Name of employee (Last, First, Middle)

 

 

 

 

 

 

 

23.

 

Phone number

 

 

 

 

 

24.

Sex

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25.

Address

 

 

 

 

 

 

 

 

 

 

 

26.

 

Date of birth

 

 

 

 

 

27.

Marital status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single

 

 

Divorced

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28.

 

Social security number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Married

Widowed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

29.

Occupation at time of injury or illness (SOC Code, if available)

 

30.

Is worker covered by PEO policy?

 

 

 

31.

Number of dependent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

children

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

32.

How long in current job?

 

33.Date of Hire

 

 

 

34.

 

Was employee paid on a piece work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or hourly basis?

 

 

 

 

 

 

Piece work

 

 

Hourly

 

35.

Hours worked

 

 

 

36. Days worked

 

 

 

37.

 

Value of perquisites per week

 

 

 

 

 

 

 

 

 

 

 

 

 

per day

 

 

 

 

 

per week

 

 

 

 

 

 

 

 

Food/meals

 

Lodging

 

 

Tips

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

38.

Wages per hour

 

 

 

39. Earnings per week (inc. overtime)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

$

 

 

 

$

$

 

 

 

 

 

$

 

 

 

 

 

 

Nature and Cause of Accident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

40.

Machine, tool, or object causing injury or illness

 

 

 

41.

 

Specify part of machine, etc.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

42.

Describe fully how injury or illness occurred

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

43.

Describe nature of injury or illness, including parts of body affected

 

 

 

 

 

 

 

 

 

 

43a. Overnight inpatient hospitalization?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

43b. Treated in Emergency Room?

Yes

No

44.

Physician (name and address)

 

 

 

 

 

 

 

 

45.

 

Hospital or Clinic (name and address)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

46.

Probable length of disability

 

47. Has employee returned

 

 

If

 

48.

At what wage?

 

49.

On what date?

 

 

 

 

 

 

 

 

 

 

 

to work?

Yes

No

yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

50.

EMPLOYER: prepared by (name, signature, title)

 

 

 

51.

 

Date

 

 

 

 

 

 

52.

Phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

53.

INSURER: (name of processor)

 

 

 

 

 

 

 

 

54. Date

 

 

 

 

 

 

55. Phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

56.

THIRD PARTY ADMINISTRATOR (if applicable)

 

57. Address

 

 

 

 

 

 

 

 

 

 

 

 

58. Phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This report is required by the Virginia Workers’ Compensation Act

 

 

 

 

 

 

Employer’s Accident Report

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VWC FORM NO. 3 (REV. 03/22/02)

INSTRUCTIONS

Employer’s Accident Report

(formerly Employer’s First Report of Accident)

VWC Form No. 3

Employer

1.Fill out this form whenever one of your employees is injured. Provide all the information requested, except the information in the top right corner. Please type or print all information in black ink. Your signature is required on line 50 of the form.

2.Send the original beige form to your insurance carrier, claims servicing agency, or third party administrator for processing. If you are self-insured, send it to your organization’s designated office for handling workers’ compensation claims.

3.If you are an employer subject to OSHA record-keeping requirements, you may retain a copy of this completed form as a supplementary record of occupational injury or illness. Use block #3 (Employer’s Case No.) to cross-reference your master log of accidents and illnesses.

4.If you need additional copies of this form, please request them from your insurance carrier, claims servicing agency, or third party administrator.

Insurance carriers, self-insured employers, Professional Employer Organizations (PEO’s), and authorized representatives

1.For accidents meeting one of the seven criteria for establishing a Commission Case File,* submit the original beige form and one copy to the Virginia Workers’ Compensation Commission at 1000 DMV Drive, Richmond VA 23220. The code for the reason for filing should be written at the top right of the form.

2.When processing these forms prior to transmittal to the Commission, please include the information requested at the top right of the form, verify that the carrier name and policy number given by the employer are accurate, and enter your name and phone number, and the date of processing at the bottom of the form.

3.Insurer code at the top right of the form refers to the five-digit code assigned by NCCI. If you are self-insured, it refers to a similar five-digit number assigned by the Virginia Workers’ Compensation Commission. A PEO must use the VWCC reference number.

4.Additional copies of this form are available without cost by writing to the Commission. Please note that color coding of the forms greatly increases the Commission’s efficiency in processing claims, and that any alternative versions of the form you develop yourself require prior approval by the Commission. Write to “Forms” at the listed Virginia Workers’ Compensation Commission address.

5.On Lines 8 and 9, the employer or carrier is to give the name of the responsible carrier as set forth on the policy (line 8) and that carrier’s policy number (line 9).

6.This form can be filed electronically. If you would like more information, please go to the Virginia Workers' Compensation Commission's Web site (www.vwc.state.va.us) or call us at (804) 367-2064.

_________________________________________________

*The criteria are (1) lost time exceeds seven days, (2) medical expenses exceed $1,000, (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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