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Virginia Workers' Compensation Claim Form

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Claim for Benefits

Please send completed form to:

VIRGINIA WORKERS' COMPENSATION COMMISSION

1000 DMV DRIVE, RICHMOND VA 23220

FILL OUT THIS FORM COMPLETELY. SEE SPECIAL INSTRUCTIONS ON REVERSE SIDE.

MEDICAL REPORTS SHOULD BE FILED WITH THIS CLAIM OR AS SOON AS POSSIBLE.

(The file number is usually printed at the top right corner of mail received from the VWC.)
Employee Name
Phone Number
Address
Soc. Sec. No.
City/State/Zip
Employer's Name
Phone Number
Address
City/State/Zip

Have you ever received an award or any compensation payments for this accident or disease?

Claimant's average gross weekly wage at the time of the accident or diagnosis of the disease was $

Claimant's Employer's workers' compensation insurance carrier is

1. Complete this section describing accident or occupational disease or both:

Accident: Accident Date:

Location of accident City or County: State:

How did the accident occur?

Nature of the injury:

Disease: Date doctor told claimant the disease was caused by work:

Name of Doctor:

Nature or name of the disease:

Date of last time exposed to cause of disease at work:

Date you last work for this employer

2. What specific benefits are you seeking? Check all that apply.

From: To:

From: To:

From: To:

From: To:

From: To:

From: To:

SIGNATURE OF CLAIMANT:

Date:

Phone:

Office use: Filed Last paid Docket for on by

Instructions

Filing a claim:

EVEN IF YOU HAVE ALREADY RECEIVED BENEFITS FROM YOUR EMPLOYER OR INSURER, YOU MUST FILE A CLAIM WITH THE VIRGINIA WORKERS' COMPENSATION COMMISSION IN ORDER TO PROTECT YOUR RIGHT TO BENEFITS UNDER VIRGINIA LAW. FILE THIS FORM WITH THE COMMISSION AS SOON AS POSSIBLE.

Complete as many of the questions on the reverse side as you can. If you do not know the answer, write "unknown" in the blank. Write "Attention APP" on the mailing envelope to help us process your claim more quickly. Send a copy of the completed form to your employer.

Special instructions on attachments:

1. If your claim has been denied, attach a copy of the denial letter.

2. If you are applying for benefits for permanent disability, attach the medical report which states the permanency rating and that you have reached maximum medical improvement.

3. If you are requesting payment of specific medical bills, attach copies of those itemized bills.

4. If you are applying for death benefit to dependents, attach: a. Copies of the birth certificates for each dependent for whom you seek benefits. b. A copy of the marriage license if you seek benefits for a spouse. c. A copy of the death certificate.

5. If you are applying for reimbursement of funeral expenses, attach a copy of the bill(s).

IMPORTANCE OF MEDICAL RECORDS:

Medical reports showing that your accidental injury or disease is work related must be filed with the Commission before processing of your claim can be completed. File these medical reports with your claim or as soon as possible.

If you are unable to obtain copies of your medical reports and bills, you may request a subpoena by sending the name and address of the medical provider to the Clerk of the Virginia Workers' Compensation Commission. A $12.00 check or money order made payable to the Sheriff of the city or county where the medical provider is located must be included for each subpoena. The Commission cannot issue subpoenae outside Virginia.

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What the Virginia Workers' Compensation Claim Form Is

The Virginia Workers' Compensation Claim Form documents an employee's work-related injury or occupational illness for purposes of benefits and medical care coordination. It captures claimant identity, employer details, date and description of the incident, treating provider information, and wage-loss or disability indicators. The form initiates a claim with the employer and the insurer and creates a record used for medical authorization, benefits calculation, and dispute resolution under Virginia law and the Virginia Workers' Compensation Commission procedures.

Why this form matters for injured workers and employers

The form creates the official record insurers and the Virginia Workers' Compensation Commission use to evaluate benefits, medical care, and wage replacement. Accurate completion speeds medical authorizations and reduces disputes.

Why this form matters for injured workers and employers

Who completes and reviews the Virginia Workers' Compensation Claim Form

The form is completed by the injured employee or their representative, reviewed by the employer and the insurer, and may be used by medical providers and legal counsel.

  • Injured employee or authorized representative completes initial incident and injury details, and signs attestations.
  • Employer or HR representative verifies employment, files required employer reports, and forwards to insurer.
  • Insurer case manager reviews medical records, authorizes treatment, and determines benefit eligibility.

Keep copies for each party and track submission dates to support any later benefit or appeals processes.

Core sections to include on a professional claim form

A complete form groups claimant data, incident facts, employer and insurer details, medical provider entries, wage information, and authorizations so reviewers can act quickly.

Claimant

Full legal name, date of birth, contact phone and address, and Social Security number for identity and benefits matching.

Incident

Exact date, time, location, and a clear description of how the injury occurred and the body part(s) affected.

Employer

Employer name, address, contact for safety/HR, job title, and regular work schedule used for wage calculations.

Medical

Treating provider name, facility, initial diagnosis, treatment dates, and authorization for release of medical records.

Wages

Recent earnings, pay frequency, and average weekly wage calculations or instructions for insurer computation.

Authorizations

Release for medical information, claimant signature, and any claimant or employer attestations required by the commission.

Required data elements at a glance

Claimant name: Legal name required
Date of injury: MM/DD/YYYY format
Employer details: Company and contact
Description of injury: Brief factual statement
Medical provider: Provider name/address
Signature: Signed and dated

Step-by-step: completing and submitting the claim form

Follow these steps to prepare a complete claim and route it correctly to employer and insurer.

  • 01
    Record details: Note injury facts and contact information immediately.
  • 02
    Complete form: Fill claimant, employer, injury, and medical sections completely.
  • 03
    Sign and date: Claimant signs; include witness or notary if required.
  • 04
    Submit: Send to employer and retain copies for insurer filing.

How to customize and file the form online

Set up a digital workflow that guides signers, captures audit data, and routes completed forms to relevant parties.

Upload document Convert original form to PDF and upload to the eSignature platform.
Add fields Place signature, date, and text fields where required on the PDF.
Assign signers Enter claimant and employer emails in signing order.
Authentication Enable email/SMS codes or stronger auth per policy.
Submit routing Configure auto-forward to insurer and HR once completed.

Where to file and who receives the completed form

Routing varies: deliver to your employer, then to the employer's insurer; some jurisdictions also accept direct filing with the state agency.

  • To employer: Provide completed form to employer or HR first.
  • To insurer: Employer typically forwards to their workers' comp insurer.
  • State filing: File with the state commission if required by local rules.
  • Retain copy: Keep a signed copy for claimant records.

Digital delivery, file types, and integrations

Use PDF or DOCX formats and choose an eSignature platform that supports audit trails and secured storage.

  • File formats: PDF and DOCX supported
  • Integrations: Salesforce, NetSuite, Google Workspace
  • Security: TLS and AES-256 encryption

Typical timelines and processing expectations

Timely reporting and submission reduce benefit delays; specific deadlines may vary by employer policy and state requirements.

Report to employer:

Report the injury as soon as possible; prompt notice supports timely benefits.

Employer filing:

Employers often notify insurer within 7–10 days of notice.

Medical authorization:

Insurer usually authorizes initial treatment within days of receiving form.

Claim determination:

Insurer decision typically within weeks, depending on investigation.

Appeals window:

Deadlines for appeals vary; review state commission instructions carefully.

Common mistakes that delay benefits

  • Incomplete or illegible injury descriptions that require follow-up from medical or employer sources.
  • Incorrect claimant identifiers such as SSN or birthdate that prevent insurer matching.
  • Failing to sign or date authorizations for medical records and treatment.
  • Not retaining a signed copy or failing to confirm employer submission and insurer receipt.

Consequences of errors or late submissions

Late notice: May reduce benefits
Wrong SSN: Triggers withholding or reporting issues
Missing signature: Claim may be invalidated
No medical release: Delays treatment authorization
HIPAA violations: Potential fines and corrective action
Employer penalties: State fines for noncompliance

Comparing common eSignature options for completing and routing the form

Platform pricing and feature sets vary; signNow is listed first per comparison standards and columns use published per-user pricing where available.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial No No No No
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Frequently asked questions about the Virginia Workers' Compensation Claim Form

Answers address common execution, submission, and legal-validity questions to reduce processing delays and compliance risk.


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