Fillable First Report of Injury (National American Insurance Company)

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First Report of Injury (National American Insurance Company)

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VWC Form #3
Rev. 10/08
First Report of Injury
Virginia Workers’ Compensation Commission
1000 DMV Drive Richmond Virginia 23220
1-877-664-2566
SEE INSTRUCTIONS ON REVERSE SIDE
www.vwc.state.va.us
Reason for filing:
VWC Jurisdiction Claim #:
(If assigned)
Claim Administrator File#:
Employer
Employer’s Legal Name
Federal Employer Identification Number (FEIN)
Employer’s 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 Worker’s 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)
Date Phone number
Submitter’s Address
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.
*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.
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Completed 29 July 2021

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