Claim for Benefits Form

The injured worker must file a claim with the Virginia Workers’ Compensation Commission in order to protect their right to benefits under Virginia law, even if there have been payments by the employer or claim administrator for time missed from work because of the injury or for medical treatment for the injury.

Instructions: 

To protect your rights as an injured worker, you must complete a Claim for Benefits Form and return it to the Commission. This form can be filed electronically using the Commission’s WebFile system once the injured worker receives a PIN in a separate mailing. To file online, set up a WebFile account at https://webfile.workcomp.virginia.gov. The Claim for Benefits Form can also be filed by mail or in person at 333 E. Franklin St., Richmond, VA 23219, or filed via fax at 804-823-6956.

Even if you are not requesting specific benefits at this time, you should still submit the Claim for Benefits Form within two years of the date of your accident or diagnosis of disease to protect your rights for benefits. If you are requesting specific benefits or if the claim administrator has denied your claim, complete the Claim for Benefits Form and submit the medical reports either attached to the form, or as soon as possible thereafter. You may obtain copies of your medical records directly from your physician or you may request a subpoena by sending the name and address of the medical provider to the Clerk of the Virginia Workers’ Compensation Commission. A $12.00 money order made payable to “Sheriff” must be included for each subpoena. The Commission cannot issue a subpoena outside of Virginia.

For assistance, call the Virginia Workers’ Compensation Commission’s Customer Contact Center toll-free at 877-664-2566 or email questions@workcomp.virginia.gov.

Benefits Covered under the Virginia Workers’ Compensation Act:

  • Lifetime Medical Benefits – Payment for medical treatment/expenses for the injury or occupational disease, now and in the future.
  • Temporary Total Disability - Wage loss replacement while completely out of work. Must be medically authorized.
  • Temporary Partial Disability – Wage loss replacement while partially out of work, or working light duty. Must be medically authorized.
  • Permanent Partial Disability – Compensation for loss of use of a body part, amputation, disfigurement/bodily scarring, loss of hearing, loss of vision or lung disease. Must be medically supported.
  • Medical Expenses – Payment/reimbursement of medical bills, or out of pocket expenses, such as prescription and mileage/transportation. Must provide bills, receipts and/or mileage logs.
  • Death Benefits – Payment/reimbursement of funeral/transportation expenses or wage loss replacement for surviving spouse, children, or certain other dependents. Death certificate, Marriage License and/or Birth Certificate(s) must be provided.
  • Other – Benefits not previously mentioned (vocational rehabilitation, specific medical treatment/procedure, panel of physicians, etc.).