The Virginia Workers’ Compensation Claim Form

The Virginia Workers’ Compensation Commission has a claim form that will need to be completed if you are looking to file a workers’ compensation claim.

The basic elements of this form include:

  • Worker Identity Information – Name, Address, Phone Numbers
  • Employer Identity Information – Name, Address, Phone Numbers
  • The worker’s gross weekly wages
  • Injury information
    • Body parts affected,
    • How the injury occurred,
    • Where it happened, and
    • When it happened.
  • If the worker is claiming compensation for an occupational disease, the worker should disclose
    • The name of the disease
    • The date the worker last worked for the employer
    • The date a doctor told the worker the disease was work related
  • Additional items the worker can include on the form are:
    • Request for a lifetime award of medical benefits
    • When the worker lost work – the dates
    • When the worker received less pay while working – the dates
    • If there was a loss of use or an amputation of a body party, loss of hearing/vision, lung disease or bodily scarring/disfigurement.
    • Whether the worker has medical bills or transportation expenses that haven’t been paid.
    • Whether death benefits are being requested.

Speak with a Workers’ Compensation Lawyer in Norfolk for More Information

When you’ve been hurt in the course of your job, you worry about getting your medical bills and your wages paid. You worry if you’ll ever recover. If you have acquired a disease because of work, you likely have the same concerns. Joe Miller has helped thousands of clients with those worries by properly filing and proving their claims, and he is ready to help you. To learn more, contact Norfolk attorney Joe Miller at Joe Miller Law, Ltd., by calling (888) 694-1671.