Fill and Sign the Report Workers Compensation 497427887 Form

     Case of                                                                                                                                                                                                - THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE WORKERS' COMPENSATION ACT. Commonwealth of Virginia Virginia Workers' Compensation Commission 1000 DMV Drive,, Richmond, Virginia 23220 VWC Claim No. SUPPLEMENTARY REPORT If Employer's Accident Report did not show that the injured had returned to work, an Employer's Supplemental Report of injury should he completed and filed immediately after return to work of the employee. In the event of the death of the employee, this report should be filedimmediately. 1 Name of Employer 2 Office Address: No. and St. City or Town State 3 Insured by: Name of Company 4 Name of Injured (in full) Last Firs t Middle Name 5 Present address: No. and St. City or Town State 6 Date of Injury Date Day of Week Hour of Day AM or PM 7 Date Disability began Date AM or PM 8 Has injured returned to work? If so, date and hour AM or PM 9 Is injured person earning same wages as before Yes or No If not, explain injury? 10 If disability has not terminated, state probable date of termination of disability 11 Has injured died? If so, date of death AM or PM NOTE: This form is not an agreement and its filing is not sufficient to terminate an outstanding award. Date of this report Firm Name Signed by Official Title VWC#3A (Rev 9/1/99)