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Forms

You can get many of the forms you need directly from this page. Click on the desired form to display it on-line. It may be printed from your browser. (In Netscape and Internet Explorer, select "File, Print" from the menu.)

Some of these forms must be submitted on paper of a specific color. Where a specific color is required, the Commission will not accept a form printed on different color paper. The required paper color is given to the right of the name of each form. The paper specified is Hammermill paper.

**(Forms that are in Adobe PDF format require Adobe Acrobat Reader to view and print. These forms are indicated by '**'. A link to Adobe's website is provided at the bottom of this page for anyone who requires the software. It is available free of charge. Some of these forms are compressed [zipped]. Forms that are zipped need to be downloaded and are indicated by a 'Z').

*** (Forms that are in HTML format are indicated
by '***').

*** (Forms that are in WORD format are indicated by the '***').

Form Name
Paper Color and Type
Any white paper

Initial Claim for Workers' Compensation Benefits **
(Form 5)
This form is typeable in Adobe Reader. Please fill out completely, print, and mail to VWC.

Preferably blue paper

Employer's Application for Hearing **
(Form 5A)
This form is typeable in Adobe Reader. Please fill out completely, print, and mail to VWC.

Requires blue paper

Forms for Settling a Case by Petition and Order (P&O)***
Any white paper

Agreement to Pay Benefits **
(Form 4)
This form is typeable in Adobe Reader. Please fill out completely, print, and mail to VWC.

Requires green paper

Employer's Accident Report **
(Form 3 - formerly Employer's First Report of Accident)
This form is typeable in Adobe Reader. Please fill out completely, print, and mail to VWC.

Requires tan paper
Request for Mediation***
Any white paper
Request for Expedited Hearing ***
Any white paper

Report of Minor Injuries **
(Form 45-A)
This form is typeable in Adobe Reader. Please fill out completely, print, and mail to VWC.

Any white paper

Report of Medical Costs **
(Form 45-G)
This form is typeable in Adobe Reader. Please fill out completely, print, and mail to VWC.

Any white paper

Termination of Wage Loss Award **
(Form 46 -formerly Agreed Statement of Fact)
This form is typeable in Adobe Reader. Please fill out completely, print, and mail to VWC.

Requires Goldenrod paper

Wage Chart *** (Form 7A)
This form is typeable in Adobe Reader. Please fill out completely, print, and mail to VWC.
example of properly completed form
example of properly completed form with an 8 day
(or more) gap
NOTE: If an injured employee lost more than seven consecutive calendar days, although not in the same week, these periods should be noted on the wage chart using an asterick (*) in the "Gross amount paid, including over time" column. §65.2-101.
Any white paper
Supplementary Report **
(Form 3A)
This form is typeable in Adobe Reader. Please fill out completely, print, and mail to VWC.
Any white paper

Supplementary Report for Fatal Accidents **
(Form 3B)
This form is typeable in Adobe Reader. Please fill out completely, print, and mail to VWC.

Any white paper
Memorandum of Agreement for Payment of Compensation in a Fatal Case ***
(Form 35)
This form is typeable in Adobe Reader. Please fill out completely, print, and mail to VWC.
Any white paper
Physician's Report **
(Form 6)
This form is typeable in Adobe Reader. Please fill out completely, print, and mail to VWC.
Any white paper

Amputation Chart (Form 7)
Hand **
Foot **
This form is typeable in Adobe Reader. Please fill out completely, print, and mail to VWC.

Any white paper
Lump Sum Agreement **
(Form 12A)
This form is typeable in Adobe Reader. Please fill out completely, print, and mail to VWC.
Any white paper
Request for Peer Review **
(Form PR50)
This form is typeable in Adobe Reader. Please fill out completely, print, and mail to VWC.   
Any white paper
Overview of the Peer Review Program ** 
(Form PR51)
Any white paper
Supplemental Agreement to Pay Benefits **
(Form 4A - formerly Supplemental Memorandum of Agreement)
This form is typeable in Adobe Reader. Please fill out completely, print, and mail to VWC.
Requires green paper
Supplemental Agreement to Pay Varying Temporary Partial Benefits ***
(Form 4G)
This form is typeable in Adobe Reader. Please fill out completely, print, and mail to VWC.
Any white paper
COLA/Social Security verification request (CA51)**
Any white paper
Subpoena Forms
Any white paper
** Forms require Adobe Acrobat Reader to view and print. If this software, or an updated version, isn't currently on your computer, you may download and install it at no charge by visiting the Adobe website