VWC Forms

VWC Form
ADR Mediator Evaluation Form
Amputation Chart - Foot (Form 7)
Amputation Chart - Hand (Form 7)
Annual Payroll Report of City, Town or County Operating as a Self-Insurer (Form 26C)
Annual Report of Premiums, Assessments, Etc., Received by Insurance Carriers (Form 26A)
Annual Report of Self-Insurer's Payroll (Form 26)
Annual Report of Self-Insurer's Payroll by City, Town or County School Boards (Form 26B)
Application for Individual Self-Insurance (Form 20)
Attending Physician Report (Form 6)
Award Agreement
Certificate of Service
Certificate of Workers' Compensation Insurance (Form 61A)
Certificate of Workers' Compensation Insurance (Form 61A) - ONLINE
Change In Condition Claims Response Form
Claim for Benefits Form
Coal Workers' Pneumoconiosis Claim Form
COLA Request Form (CA51)
Electronic Claims Administrator Address List
Electronic Trading Partner Agreement Form
Electronic Trading Partner Profile
Electronic Transmission Profile
Employer's Application for Hearing (Form 5A)
Expedited Hearing Request Form
Fatal Award Agreement
Fatal SSA Verification
First Report of Injury
GSIA Application
Letter for Beneficiary in Fatal Case
Letter of Credit
Letter to Sheriff
Mediation Consent Form A - All Parties Have Legal Counsel
Mediation Consent Form B - All Parties Do Not Have Legal Counsel
Mediation Request Form
Medical Care Provider Application Response Form
Medical Provider Inquiry
Notice Terminating Prior Rejection of Coverage (Form 17A)
Notice Terminating Prior Rejection of Coverage (Form 17A) - ONLINE
Parental Guarantee (Form 22)
PEO Access Form
PEO Parental Guarantee
Petition Under Virginia Birth-Related Neurological Injury Act (Form BR1)
Pre-Hearing Motions Order
Pre-Hearing Statement Order - Claimant's Claim
Pre-Hearing Statement Order - Claimants Claim and Employers Application
Pre-Hearing Statement Order - Employer's Application
Pre-Hearing Statement Order - Medical Care Provider's Application
Referral for Lack of Coverage
Referral for Lack of Coverage - ONLINE
Rejection of Coverage (Form 16A)
Rejection of Coverage (Form 16A) - ONLINE
Sample Affidavit
Sample Informational Letter
Sample Order
Self Insurance Survey - Commercial (Form 23A)
Self-Insurance Bond (Form 21A)
Self-Insurance Survey - Government (Form 23B)
Subpoena Duces Tecum - Attorney Issued
Subpoena Duces Tecum - Requesting Party
Subpoena Duces Tecum - VWC Issued
Subpoena for the Taking of Deposition
Termination of Wage Loss Award Form
Wage Chart (Form 7A)
Waiver of Occupational Disease (Form 9A)
WebFile Attorney Registration Form
Witness Subpoena - Attorney Issued
Witness Subpoena - VWC Issued