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?Yes
Fillable fields41
Avg. time to fill out8 min 42 sec
Other namesinsurer, va wc form 3, 43b, VWC

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.

How to Edit Vwc Form No 3 Online for Free

The form vwc form no 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 insurer

Fill in the Phone, Number Injured, Worker, ID, Number Single, Divorced, Married, Widowed, Type, of, ID Social, Security, No Green, Card Unknown, Employment, Visa Passport, No Female, Injured, Worker and Dateofbirth areas with any content that is required by the application.

step 2 to entering details in insurer

Mention the necessary information in VW, C, Form and Rev part.

Filling out insurer 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.

Watch Vwc Form No 3 Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .