VWC Forms

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