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The First Injury Report form plays a crucial role in the workers' compensation process in Virginia, enabling accurate documentation of workplace injuries. This form must be completed by the employer whenever an employee sustains an injury during work. Key information required includes the employer's legal name, Federal Employer Identification Number, and details about the incident—such as the date, time, location, and a thorough description of how the injury occurred. Specific sections are dedicated to capturing the identity of the injured worker, including contact information, Social Security number, and occupation at the time of the injury. In cases of fatal incidents, additional details regarding the deceased's marital status and dependent children must also be provided. It is important for employers to ensure that the form is legibly filled out, signed, and dated, reflecting their responsibility in the reporting process. The completed form must be submitted to the appropriate claim administrator, who will relay the information to the Virginia Workers’ Compensation Commission. All injuries occurring in the course of employment require reporting, as mandated by the Virginia Workers’ Compensation Act, making the accurate and timely completion of this form vital for ensuring that both employees and employers fulfill their obligations under the law.

First Injury Report Example

 

 

First Report of I nj ury

 

 

 

 

 

Virginia Workers’ Compensation Commission

 

Reason for filing:

 

 

 

 

 

 

 

 

 

 

 

 

 

1000 DMV Drive Richmond Virginia 23220

 

VWC Jurisdiction Claim # :

 

 

 

 

 

1-877-664-2566

 

 

 

 

 

 

 

 

 

 

(I f assigned)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SEE I NSTRUCTI ONS ON REVERSE SI DE

 

Claim Administrator File# :

 

 

 

 

 

 

 

 

 

www.vwc.state.va.us

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer

 

 

 

 

 

 

 

 

 

Employer’s Legal Name

 

 

 

Federal Employer I dentification Number (FEI N)

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer’s Mailing Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name/ FEI N of Entity on Policy

 

 

 

Nature of Business

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name and Address of I nsurer or Self-I nsurer for this Claim

Policy Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time and Place of Accident

 

 

 

 

 

 

 

Location where accident occurred

Date of injury

 

Hour of injury

 

 

 

 

 

 

 

 

 

 

 

 

 

a.m.

 

p.m.

 

 

 

 

 

 

 

 

 

Date injury or illness reported

I f fatal, give date of death

 

I f fatal, give marital status

 

 

 

 

 

 

 

 

 

 

 

Single

Divorced

 

 

 

 

 

 

 

I f fatal, give number of dependent children

 

 

 

 

 

 

 

 

 

 

 

 

 

Married

Widowed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I nj ured W orker

 

 

 

 

 

 

 

 

 

Name of I njured Worker

 

Phone Number

 

I njured Worker I D Number

 

 

 

 

 

 

 

 

 

 

 

 

I njured Worker’s mailing address

 

 

 

 

Type of I D

 

 

 

 

 

 

 

 

 

 

 

 

Social Security No.

 

 

Employment Visa

 

 

 

 

 

 

 

 

 

Green Card

 

 

Passport No.

 

 

 

 

 

 

 

 

 

Unknown

 

 

 

Occupation at time of injury or illness

 

Date of birth

 

Sex

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

Female

 

 

Nat ure and Cause of Accident

 

 

 

 

 

 

 

Machine, tool, or object causing injury or illness

 

 

 

 

 

 

 

 

 

 

 

 

 

Describe fully how injury or illness occurred

 

 

 

 

 

 

 

 

 

 

 

 

Describe nature of injury, occupational disease, or illness, including body parts affected

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signat ures

 

 

 

 

 

 

 

 

 

 

Submitter (name, signature, title)

 

 

Date

 

Phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Submitter’s Address

VW C Form # 3

Rev. 10/ 08

First Report of I nj ury

Filing I nst ruct ions

The Virginia Workers’ Compensation Act requires that ALL injuries occurring in the course of employment be reported to the Commission pursuant to Va. Code §65.2-900.

Employer

The employer is responsible for accurately completing all sections of this form when an employee is injured. I t should be typed or legibly printed, signed, and dated by the preparer. Send the original form to the claim administrator for the insurance company who provided insurance coverage on the date of the occurrence. The claim administrator will report this information to the Commission.

Contact your workers’ compensation insurance provider for additional information.

Claim Administ rat or

Claim administrators who are EDI enabled will use the information contained on the paper form and submit electronic data to the Commission.

Claim administrators who are NOT EDI enabled must immediately file the completed form with the Commission. Please note: EDI is mandatory no later than June 30, 2009, after which time paper reports will no longer be accepted. Until you are in EDI production, mail the completed form to the Virginia Workers’ Compensation Commission, 1000 DMV Drive, Richmond, VA 23220. At the top of the form, use a numerical code (1-7) to indicate the reason for filing the form for accidents meeting one of the filing criterion.* I f none of the criteria apply, you must still report the accident, but may use either Form 45A or this form to do so. (Leave “reason for filing” blank in such a case.)

For questions or assistance in completing the form, please contact the Commission toll-free at 877-664- 2566.

*Criteria for filing are: (1) lost time exceeds seven days; (2) medical expenses exceed $1,000.00; (3) compensability is denied; (4) issues are disputed; (5) accident resulted in death; (6) permanent disability or disfigurement may be involved; and (7) a specific request is made by the Virginia Workers’ Compensation Commission.

Get First Injury Report PDF Form

Form Characteristics

Fact Name Description
Purpose This form is used to report injuries occurring in the course of employment to the Virginia Workers’ Compensation Commission.
Location The form must be submitted to the Virginia Workers' Compensation Commission, located at 1000 DMV Drive, Richmond, VA 23220.
Governing Law The reporting requirement is governed by the Virginia Workers’ Compensation Act, specifically Va. Code §65.2-900.
Employer's Responsibility The employer must accurately complete all sections of the form. It must be typed or printed legibly.
Filing Criteria There are specific criteria for filing the form, including lost time exceeding seven days or medical expenses over $1,000.
Submission Method If the claim administrator is EDI enabled, they will submit the information electronically. If not, the paper form must be filed directly with the Commission.
Deadline for EDI EDI submission became mandatory on June 30, 2009. After this date, only electronic reporting is accepted.
Fatality Reporting If the incident is fatal, the form must include the date of death and the marital status of the deceased individual.
Contact Information For assistance, individuals can contact the Commission at 1-877-664-2566.

Guidelines on Utilizing First Injury Report

After completing the First Injury Report form, ensure that all necessary information is accurately provided before submitting it to the claim administrator. This process is crucial for proper documentation and processing of the claim.

  1. Obtain a copy of the First Injury Report form.
  2. Fill in the **Claim Number** if assigned, or leave blank if not.
  3. Write the **Employer’s Legal Name** and **Federal Employer Identification Number (FEIN)**.
  4. Provide the **Employer’s Mailing Address**.
  5. State the **Name/FEIN of the Entity on the Policy** and the **Nature of Business**.
  6. Indicate the **Name and Address of the Insurer or Self-Insurer** for this claim, along with the **Policy Number**.
  7. Specify the **Time and Place of Accident**. Include the location, the date and hour of the injury.
  8. Document the **Date Injury or Illness was Reported**.
  9. If the injury is fatal, indicate the **Date of Death** and the **Marital Status** of the deceased.
  10. List the number of **Dependent Children** if applicable.
  11. Provide the **Injured Worker’s Name**, **Phone Number**, and **ID Number**.
  12. State the **Injured Worker’s Mailing Address** and **Type of ID** (e.g., Social Security Number, Employment Visa, etc.).
  13. Indicate the **Occupation at the Time of Injury** and the **Date of Birth**.
  14. Check the **Sex** of the injured worker (Male/Female).
  15. Describe the **Nature and Cause of Accident**, including the object causing the injury.
  16. Provide a detailed account of **how the injury or illness occurred**.
  17. Describe the **nature of the injury, occupational disease, or illness**, including affected body parts.
  18. Gather the **Signature** of the Submitter, along with their **Name**, **Title**, **Date**, and **Phone Number**.
  19. Include the **Submitter’s Address**.
  20. Check for completeness and accuracy, then submit the form to the claim administrator.

What You Should Know About This Form

What is the purpose of the First Injury Report form?

The First Injury Report form is used to report any injuries that occur in the workplace. It ensures that incidents are documented correctly and adequately, complying with the Virginia Workers’ Compensation Act. Complete and accurate reporting helps initiate the workers’ compensation process and allows for the appropriate benefits to be provided to injured workers.

Who is responsible for completing the First Injury Report form?

The employer holds the responsibility for filling out the First Injury Report form. It is crucial that all sections of the form are completed accurately and legibly. The person who prepares the form must also sign and date it. Once completed, the original form should be sent to the claim administrator associated with the employer’s insurance provider.

What should be included in the description of the injury?

A detailed description of how the injury occurred is important. This includes noting the nature and cause of the accident, the machine or object involved, and the exact circumstances leading to the injury. Additionally, detailing the nature of the injury or occupational illness, including the specific body parts affected, provides the necessary context for the claim and aids in processing it accurately and efficiently.

What should I do if I need assistance with the form?

If you require assistance in completing the First Injury Report form, you can contact the Virginia Workers’ Compensation Commission. They have a toll-free line at 1-877-664-2566 where representatives can provide guidance and answer any questions you might have about the form or the reporting process.

Common mistakes

Completing the First Injury Report form is crucial for ensuring that workers’ compensation claims are handled properly. However, many individuals make mistakes that can delay the process or cause complications down the line. One common error is failing to provide all required information. Each section of the form is important, and any missing data can lead to delays in processing the claim.

Another frequent mistake is neglecting to sign and date the form. Without a signature, the submission is incomplete. It’s vital for the individual preparing the form to acknowledge their role in filing the information. Additionally, people often forget to accurately identify the employer. The legal name and address of the employer must be clear. Errors in this section can result in confusion about who is liable for the claim.

Many filers do not clearly describe the accident. The section dedicated to describing how the injury occurred should include detailed information. A vague description makes it difficult for the claim administrator to assess the situation properly. Furthermore, some individuals overlook the necessity of specifying the time and place of the injury. Precise details about when and where the injury took place significantly contribute to the clarity of the report.

Additionally, individuals sometimes fail to indicate the nature of the injury itself. It is not enough to simply state that an injury occurred; the form should detail the type of injury and the body parts affected. Mistakes in this part can lead to misunderstandings regarding the claim. Another area of concern is the identification of the injured worker. The form must have correct personal information, including a valid Social Security number or type of ID. Discrepancies here can complicate the verification process.

Sometimes, submitters overlook the instructions regarding the reason for filing. It's essential to use the numerical code provided on the form to indicate why it’s being submitted. If none of the criteria apply, individuals may face further complications if this is not addressed. Misunderstanding the filing basis can lead to unnecessary delays.

Lastly, filers often forget to double-check contact information. Accurate phone numbers and addresses are essential for prompt communication. Any errors in this section can hinder the insurance company’s ability to reach out for additional information or clarification. Taking careful steps to ensure all details are correct can save time and help ensure that compensation is received appropriately.

Documents used along the form

The First Injury Report form serves as a crucial document in the process of reporting workplace injuries. Additionally, several other forms and documents complement this main report and are often necessary to ensure that all necessary information is captured accurately. These documents play important roles in the workers' compensation process, helping both the employer and employee navigate the complexities of filing a claim.

  • Subsequent Injury Report: This document is used to report any changes or developments in the employee's medical condition after the initial injury report has been filed. It provides updated information about treatments, recovery progress, and any new symptoms that may arise.
  • Claim Authorization Form: This form is essential for granting permission to the insurance provider to access medical records related to the injury. It ensures that the insurance company has the necessary information to evaluate the claim thoroughly.
  • Medical Treatment Plan: A medical treatment plan outlines the recommended course of treatment for the injured worker. It is provided by a healthcare professional and includes information about the nature of the injury, prescribed therapies, and expected outcomes.
  • Employee Wage Statement: This document details the wages of the injured employee prior to the injury. It is important for calculating any potential workers' compensation benefits and ensures that the employee is compensated fairly based on their earnings.

Understanding these additional forms can greatly facilitate the process of reporting and managing workplace injuries. The collaboration between the injured worker, the employer, and the insurance provider is vital in ensuring that the claim is processed efficiently and compassionately.

Similar forms

  • Workers' Compensation Claim Form: Similar in function, this form also documents workplace injuries and is used to initiate a claim for benefits. It requires basic information about the injured employee and the nature of the injury, streamlining the claims process for workers' compensation benefits.

  • Accident Report Form: This form serves to detail the circumstances surrounding an accident at the workplace. Like the First Injury Report, it includes data about the time and location of the incident, as well as witness accounts, making it useful for incident analysis.

  • Incident Report Form: Also oriented toward documenting workplace incidents, this form captures information about unsafe conditions or behaviors leading to injuries. Similar to the First Injury Report, it emphasizes the need to report incidents promptly.

  • Medical Release Form: While the focus is on health information, this document allows for the sharing of medical records with employers or insurers. Its role in facilitating claims by providing necessary medical details parallels the health-related queries found in the First Injury Report.

  • Employer’s First Notice of Injury: This document is required by some jurisdictions and serves a similar purpose as the First Injury Report. It notifies relevant parties of an employee's injury, ensuring prompt action and investigation.

  • OSHA Incident Report: This report is required for workplace injuries that need to be recorded by OSHA. Like the First Injury Report, it seeks to document the details of the injury, ensuring compliance with safety regulations.

  • Claim for Compensation Form: This form is submitted to request benefits once an injury claim is filed. It mirrors the First Injury Report by requiring information on the injury and the claimant's details to assess compensation eligibility.

  • Disability Benefits Application: If an injury leads to long-term disability, this form is used to apply for benefits. The necessity for detailed injury descriptions links it closely with the First Injury Report, aiding in assessing ongoing support needs.

Dos and Don'ts

Things to Do when Filling Out the First Injury Report Form:

  • Carefully complete all sections of the form.
  • Print legibly or type the information to ensure clarity.
  • Sign and date the form after completing it.
  • Send the original form to the claim administrator for the insurance company.
  • Contact the Virginia Workers’ Compensation Commission for assistance, if needed.

Things Not to Do when Filling Out the First Injury Report Form:

  • Do not leave any sections blank that require information.
  • Do not submit a paper form if your claim administrator is EDI enabled.
  • Avoid using unclear handwriting that could lead to misunderstanding.
  • Do not delay in submitting the report to the Commission.
  • Never assume the claim administrator knows about the incident without having the report.

Misconceptions

Here are five common misconceptions about the First Injury Report form:

  • It is only necessary for serious injuries. Many believe the form is required only for severe injuries. However, all injuries that occur in the course of employment must be reported, regardless of their severity.
  • The employer is not responsible for completing the form. Some may think that the injured worker or their family is responsible for the report. In reality, the employer must accurately complete all sections of the form.
  • The form can be submitted after a long delay. There is a misconception that there is no deadline for submission. The form should be submitted as soon as possible following the injury to ensure compliance with the law.
  • Filing the form guarantees compensation. Some people believe that submitting the First Injury Report automatically leads to compensation. In fact, this form initiates the process, but compensation is determined based on various factors.
  • Only the claim administrator needs to complete the form. It is a misconception that only the claim administrator is responsible for the report. The employer must provide accurate information, ensuring the form is signed and dated by the preparer.

Key takeaways

Filling out the First Injury Report form is a critical step in the process of reporting workplace injuries. Here are some key takeaways for successfully completing and using this form.

  • Accuracy is Essential: The employer must complete all sections of the form accurately. This includes details like the employer’s information, nature of the accident, and specifics about the injured worker.
  • Submit Promptly: The completed original form should be sent immediately to the claim administrator for the insurance provider. Timeliness is crucial to ensure compliance with the Virginia Workers’ Compensation Act.
  • Know Your EDI Status: If your claim administrator is EDI enabled, they will electronically submit the required information. For those who are not, the completed form must be mailed directly to the Virginia Workers’ Compensation Commission.
  • Follow the Filing Criteria: Be mindful of the reasons for filing. Certain criteria dictate when the form is necessary, such as if lost time exceeds seven days or if medical expenses surpass $1,000. If none apply, reporting is still required, but you may use an alternative form.

By keeping these takeaways in mind, you can navigate the complexities of the reporting process more effectively.

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