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.

Even if you are not requesting specific benefits at this time, you should still submit this form, with Part A completed, within two years of the date of your accident or diagnosis of disease. If you are requesting specific benefits or if the claim administrator has denied your claim, complete Part B of this 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 subpoenae outside Virginia.

This form may be filed electronically through the Commission’s WebFile system at To file electronically, the user must have a valid and active WebFile account. This form may be filed by mail or in-person at 333 E. Franklin St., Richmond, VA 23219. This form may also be filed by fax 804-823-6956.

For questions or assistance with completing this form, please contact the Virginia Workers’ Compensation Commission toll free at 1-877-664-2566 or by email at

Benefits Covered under the Virginia Workers’ Compensation Act:

  • Lifetime Medical Benefits – Payment for expenses related to the injury or occupational disease. Includes payment/reimbursement of out of pocket medical, prescription and transportation expenses.
  • Wage Loss Replacement (Temporary Total/Temporary Partial Disability): Full or partial wage loss replacement for medically authorized disability from work. (The first seven calendar days of incapacity is a waiting period but if incapacity extends beyond that period, compensation should commence on the eighth day of disability.)
  • Permanent Partial Disability – Compensation for loss of use of a body part, loss of hearing/vision, amputation, lung disease or bodily disfigurement/scarring.
  • Permanent Total Disability – Lifetime wage replacement for loss of both hands, arms, feet, legs, eyes or any two in the same accident, or is paralyzed or disabled from a severe brain injury.
  • Death Benefits – In cases where injury results in death, surviving spouse, children, or certain other dependents may be entitled to wage loss replacement benefits and payment of funeral/transportation expenses.
  • Other: Mileage reimbursement, Cost of Living Increases, if eligible. (total wage loss and fatal benefits)