First Report Of Injury {3}

VWC Form #3Rev. 10/08 First Report of Injury Virginia Workers222 Compensation Commission Richmond Virginia 232 1-877-664-2566SEE INSTRUCTIONS ON REVERSE SIDE www.vwc.state.va.usReason for filing: VWC Jurisdiction Claim #: (If assigned) Claim Administrator File#: Employer Employer222s Legal Name Federal Employer Identification Number (FEIN) Employer222s Mailing Address Name/FEIN of Entity on Policy Nature of Business Name and Address of Insurer or Self-Insurer for this Claim Policy Number Time and Place of Accident Location where accident occurred Date of injury Hour of injury a.m. p.m. If fatal, give date of death Date injury or illness reported If fatal, give number of dependent children If fatal, give marital status Single Divorced Married Widowed Injured Worker Name of Injured Worker Phone Number Injured Worker ID Number Injured Worker222s mailing address Type of ID Social Security No. Employment Visa Green Card Passport No. Unknown Occupation at time of injury or illness Date of birth Sex Male Female Nature 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 Signatures Submitter (name, signature, title) DatePhonenumber Submitter222s Address American LegalNet, Inc. www.FormsWorkFlow.com First Report of Injury Filing Instructions The Virginia Workers222 Compensation Act requires that ALL injuries occurring in the course of employment be reported to the Commission pursuant to Va. Code 24765.2-900. 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 workers222 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 Workers222 Compensation Commission, , Richmond, VA 232. 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 223reason for filing224 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 ordisfigurement may be involved; and (7) a specific request is made by the Virginia Workers222 CompensationCommission. American LegalNet, Inc. www.FormsWorkFlow.com