Fillable Claim Form Injured Worker Information Employer Information Virginia (Virginia Department of Motor Vehicles)

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Claim Form Injured Worker Information Employer Information Virginia (Virginia Department of Motor Vehicles)

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Toll-Free: 877-664-2566 | Online: workcomp.virginia.gov | Mail: 333 E. Franklin St., Richmond, Virginia 23219 Rev. 6/21
Signature
I hereby le this claim to protect my right to benets under the Virginia Workers’ Compensation Act for the injury or disease described above.
SIGNATURE (Required) PRINT DATE
Lifetime Medical Award (coverage for related medical expenses).
Wage Loss Replacement (Temporary Total Disability - Completely out of work):
From: To: From: To:
Wage Loss Replacement (Temporary Partial Disability - Partially out of work/light duty):
From: To: From: To:
Compensation for Permanent Loss (Permanent Partial Disability):
Loss of use of a body part Disfigurement/Scarring Amputation Hearing/Vision loss Lung disease
Payment/reimbursement for the following expenses (attach medical records, itemized bills, receipts, or mileage log):
Medical bills Mileage/Transportation
Prescriptions
Death benefits to dependents and/or funeral expenses.
Other:
I need assistance obtaining the following benefits. If the benefits are denied, this form will serve as a hearing request.
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How Injury Occurred
Date of Injury* Where Injury Occurred (City or County)
Jurisdiction Claim Number (JCN) Claim Administrator Number
Claim Form
*If claiming an occupational disease (use separate claim form for Coal Workers’ Pneumoconiosis):
Name of Occupational Disease Date last worked for employer Date doctor stated the disease was caused by work
Virginia Workers’ Compensation Commission
Injury
Access your claim online: webfile.workcomp.virginia.gov
Name of Company
Address
City State Zip Code
Employer’s Phone
Name
Address
City State Zip Code
Primary Phone Gross Weekly Earnings
Injured Worker Information Employer Information
Request for Benets
Parts of Body Injured
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signature
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Injury
When an individual has experienced an injury or an occupational disease in the workplace, it is important to give
immediate notice to the employer about the injury. Employers are required to le a First Report of Injury (FROI) within
ten (10) days of having knowledge of any injury.
Claim Form
Pursuant to Va. Code §65.2-601, a claim for specic benets must be led within two (2) years from the date of injury.
Even if the Claim Administrator is voluntarily paying benets, rights are not protected unless there is an Award
Order.
Award Order
If the Claim Administrator accepts the claim, an Award Agreement is sent to the injured worker. Once signed by all
parties, the Award Agreement must be led with the Commission for entry of the Award Order. An Award Order protects
the injured worker’s rights to benets.
Alternative Dispute Resolution (ADR)
Mediation is a voluntary and condential informal dispute resolution process where a neutral third party (mediator)
facilitates communication to assist the parties in mediating an agreeable solution. The purpose of mediation is to identify
issues, clarify misunderstandings, explore solutions and mediate an agreement. For further information, contact the
ADR Department at 804-205-3139.
Hearing
A hearing may be necessary to resolve disputed issues. A completed Claim Form and medical records* to support the
claim must be led for this to occur. The primary objective is to hear and decide disputed claims and issues arising
under the Virginia Workers’ Compensation Act in a prompt, fair and impartial manner.
• Lifetime Medical - payment for medical treatment/expenses for the injury or occupational disease, now and in the future.
• Temporary Total Disability - wage loss replacement while completely out of work. Must be medically authorized.
• Temporary Partial Disability - wage loss replacement while partially out of work, or working light duty. Must be medically authorized.
• Permanent Partial Disability - compensation for loss of use of a body part, amputation, disfigurement/bodily scarring, loss of hearing,
loss of vision or lung disease. Must be medically supported.
• Medical Expenses - payment/reimbursement of medical bills, or out of pocket expenses, such as prescription and mileage/transportation.
Must provide bills, receipts and/or mileage logs.
• Death Benefits - payment/reimbursement of funeral/transportation expenses or wage loss replacement for surviving spouse, children,
or certain other dependents. Death Certificate, Marriage License and/or Birth Certificate(s) must be provided.
• Other - benefits not previously mentioned (vocational rehabilitation, specific medical treatment/procedure, panel of physicians, etc).
Benets Covered under the Virginia Workers’ Compensation Act
*Medical Records & Subpoenas
Copies of medical records may be obtained from the physician. However, if copies of medical records and/or bills
cannot be obtained, a subpoena can be requested by sending the name and address of the medical provider to the
Clerk of the Commission. A $12 money order made payable to the Sheri of the city or county where the medical
provider is located must be included for each subpoena.
Ombudsman Oce
Have questions about the Virginia Workers’ Compensation Commission and no lawyer? Call the Ombuds Department
at 833-448-1681, or email ombuds@workcomp.virginia.gov. We cannot give legal advice, but all conversations will
be kept condential.
Toll-Free: 877-664-2566 | Online: workcomp.virginia.gov | Mail: 333 E. Franklin St., Richmond, Virginia 23219
Claim Form Process & Instructions
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Claim Form Injured Worker Information Employer Information Virginia (Virginia Department of Motor Vehicles)

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Completed 21 July 2021

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