Fill and Sign the Injuries Workers Compensation Form

                                                                                                                                                                                                                                                                                                                                                                                                                 / / / /Report of Minor InjuriesSubmit to: Virginia Workers' Compensation Commission 1000 DMV Drive Richmond VA 23220 See instructions on the reverse of this form. 45 - A Insurer Name of insurer or self-insurer Period covered From To Address Insurer code Insurer location Date filed Contact Person Phone number Payments NOTE: If this accident has been previously reported on Form 45A, place an 'A'' in the box by the entry. Name of employee Social Security Number Date of accident Address of employee Name and address of employer Employer Tax Identification Number Monthly medical cost Name of employee Social Security Number Date of accident Address of employee Name and address of employer Employer Tax Identification Number Monthly medical cost Name of employee Social Security Number Date of accident Address of employee Name and address of employer Employer Tax Identification Number Monthly medical cost Name of employee Social Security Number Date of accident Address of employee Name and address of employer Employer Tax Identification Number Monthly medical cost Name of employee Social Security Number Date of accident Address of employee Name and address of employer Employer Tax Identification Number Monthly medical cost Name of employee Social Security Number Date of accident Address of employee Name and address of employer Employer Tax Identification Number Monthly medical cost Name of employee Social Security Number Date of accident Address of employee Name and address of employer Employer Tax Identification Number Monthly medical cost Report of Minor InjuriesVWC Form No. 45A (rev. 911199) INSTRUCTIONS Report of Minor Injuries VWC Form No. 45A *More specifically, the seven situations in which you should NOT use this form, and should instead file an Employer's Accident Report (ERA) are when (1) lost time exceeds seven days, (2) medical expenses exceed $1,000, (3) compensability is denied, (4) issues are disputed, (5) the 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.