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VWC Forms & Documents

Forms Used in Processing Claims

Subpoena Information and Forms

Employers' Insurance Monitoring Forms

Self-Insurance Forms

Taxation Forms

Petition Under Virginia Birth-Related Neurological Injury Act

Petition Under Virginia Birth-Related Neurological Injury Act (Form BR1)

Other

Publications from the Commission are available electronically. Forms not available in electronic format may be purchased by filling out the order form below:

Order Form For Publications

Pre-10/1/2008 Forms

Accidents that occur on or after 10/1/08 must be reported to VWC electronically via EDI. For more information about EDI, click here. For accidents that occur before 10/1/08, including minor accidents (formerly reported on Form 45A), use the following form:

First Report of Injury

Other Pre-10/1/2008 Forms

Agreement to Pay Benefits (Form 4)
Amputation Chart - Foot (Form 7)
Amputation Chart - Hand (Form 7)
COLA Request Form/Social Security Verification Request (CA51)
Employer's Accident Report (Form 3 - formerly Employer's First Report of Accident)
Employer's Application for Hearing (Form 5A)
Employer's Workplace Notice (Form 1)
Noticia Sobre Compensación Laboral (Employer's Workplace Notice - Spanish Version)
Expedited Hearing Request Form
Initial Claim for Workers' Compensation Benefits (Form 5)
Lump Sum Agreement (Form 12A)
Memorandum of Agreement for Payment of Compensation in a Fatal Case (Form 35)
Notice Risk to Coal Miners (Form VWC-1B)
Peer Review Program Overview (Form PR51)
Peer Review Form (Form PR50)
Physician's Report (Form 6)
Request for Mediation
Report of Medical Costs (Form 45-G)
Report of Minor Injuries (Form 45-A)
Supplemental Agreement to Pay Benefits (Form 4A - formerly Supplemental Memorandum of Agreement)
Supplemental Agreement to Pay Varying Temporary Partial Benefits (Form 4G)
Supplementary Report (Form 3A)
Supplementary Report for Fatal Accidents(Form 3B)
Termination of Wage Loss Award (Form 46 -formerly Agreed Statement of Fact)
Wage Chart (Form 7A)
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 asterisk (*) in the "Gross amount paid, including over time" column. §65.2-101.