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First Report of Injury


Filing Instructions

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. It 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 Administrator

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.* If 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.



Employer
First Name
Required
Last Name
Required
Federal Employer Identification Number
Required
Mailing Address
Required
City
Required
State / Province
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
E-Mail Address
Required
Name/FEIN of Entity on Policy
Required
Nature of Business
Required
Name of Insurer or Self-Insurer for this Claim
Required
Address of Insurer or Self-Insurer for this Claim
Required
City
Required
State / Province
Required
ZIP / Postal Code
Required
Policy Number
Required
Time and Place of Accident
Location where accident occurred
Required
Date of Injury
Required
/ /
Hour of Injury
Required
Date injury or illness reported
Required
/ /
If fatal, give date of death
Optional
/ /
If fatal, give number of dependent children
Optional
If fatal, give marital status
Optional



Injured Worker
Name of Injured Worker
Required
Phone Number
Required
Injured Worker ID Number
Required
Injured Worker’s mailing address
Required
City
Required
State / Province
Required
ZIP / Postal Code
Required
Type of ID
Required




Occupation at time of injury or illness
Required
Date of Birth
Required
/ /
Sex
Required

Nature and Cause of Accident
Machine, tool, or object causing injury or illness
Required
Describe fully how injury or illness occurred
Required
Describe nature of injury, occupational disease, or illness, including body parts affected
Required
Submission Validation
Required
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