Fill and Sign the Va Workers Compensation Form

                                                                                                                                                                                                                                                                                                                                                                                                                / / / /Report of Medical Costs Submit to: Virginia Workers' Compensation Commission 1000 DMV Drive Richmond VA 23220 See instructions on the reverse of this form. 45- G Insurer N ame of insurer or self-insurer Period covered From To Address Insurer code Insurer location Date filed Contact Person Phone number Payments NOTE: This report is to be filed every six months and SHOULD NOT include costs previously reported. 1. VWC File Number 2. Name of employee 3. Social Security Number 4. Date of accident 5. Hospital costs 6. Physician costs 7. Miscellaneous costs 8. Rehabilitative costs 1. VWC File Number 2. Name of employee 3. Social Security Number 4. Date of accident 5. Hospital costs 6. Physician costs 7. Miscellaneous costs 8. Rehabilitative costs 1. VWC File Number 2. Name ofemployee 3. Social Security Number 4. Date of accident 5. Hospital costs 6. Physician costs 7. Miscellaneous costs 8. Rehabilitative costs 1. VWC File Number 2. Name of employee 3. Social Security Number 4. Date of accident 5. Hospital costs 6. Physician costs 7. Miscellaneous costs 8. Rehabilitative costs 1. VWC File Number 2. Name of employee 3. Social Security Number 4. Date of accident 5. Hospital costs 6. Physician costs 7. Miscellaneous costs 8. Rehabilitative costs 1. VWC File Number 2. Name of employee 3. Social Security Number 4. Date of accident 5. Hospital costs 6. Physician costs 7. Miscellaneous costs 8. Rehabilitative costs 1. VWC File Number 2. Name of employee 3. Social Security Number 4. Date of accident 5. Hospital costs 6. Physician costs 7. Miscellaneous costs 8. Rehabilitative costs Report of Medical CostsVWC Form No. 45G (rev. 9/1/9 9) INSTRUCTIONS Report of Medical Costs VWC Form No. 45G 1 . This form is to be used to report medical costs on accidents that where previously reported to the Virginia Workers' Compensation Commission on an Employer's Accident Report (ERA) because they (a) result in lost time of more than seven days; (b) involve more than $ 1,000 in medical costs; or (c) involve any fatality, permanent disability, or disfigurement. This report is to be submitted every six months.* 2. Please type or print all information in black ink. All the information listed is required. Be sure to include all the ''insurer'' information at the top of the form. 3. Additional copies of this form are available without cost by writing to the Commission. Please note that any alternate versions of the form you develop require prior approval. Write to ''Forms'' at thelisted Virginia Workers' Compensation Commission address. 4. If you are interested in electronic transmission of this information, and have not previously discussed the issue with the Commission, please send a letter to ''Information Systems Department'' at the Virginia Workers' Compensation Commission. Please provide a brief indication of your current data processing and communication capabilities, and the name and phone number of the person in your organization who should be contacted about such issues. *If this accident has not been previously reported to the Commission, and does not meet one of the following seven criteria, you should use VWC Form No. 45A (Report of Minor Injuries) rather than this report: (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.