claim for benefits formUpdate: In January of 2019 the Virginia Workers Compensation Commission released an updated Claims Form. This article has been updated to reflect those changes. 

The Virginia Workers Compensation has revised the Claim Form and it is now known as the Claim Form.  When injured in an accident at work, you want to receive the proper compensation benefits based on your injuries, lost wages, and needed medical care. In the state of Virginia, you will need to file a workers’ compensation Claim Form. This completed form must be sent to the Virginia Workers’ Compensation Commission to protect your right to receive benefits.

Even if your employer has already made payments to you based on the number of hours that you have already missed work or because the employer takes full responsibility for the injuries you incurred, you should still fill out and send in the Claim Form, as this is the first step in the legal process of requesting that your benefits be protected.

Filling Out the Virginia Worker’s Claim Form

Always ensure that each section of the form is filled out as completely and as accurately as possible. Providing as much information as possible will ensure that your claim will be accepted by the insurance claim administrator.

The Claim Form needs to be filled out within two years of the accident or when you become diagnosed with a work-related disease. Even if you aren’t claiming any type of benefit, such as permanent disabilities or lost wages, this part of the benefits form should still be completed.

At the top of the form, you will see the Jurisdiction claim number and the claim administrator number. You can leave both lines blank if you don’t yet have this information, as that will can be completed by the Virginia Workers’ Compensation Commission.

Injured Worker/Employer Information Section

Fill in all your personal information: your name or the name of the injured party seeking benefits if you are completing the form for them, the injured worker’s address, work phone number, and home phone number. You also must complete the employer information section beside the personal information section. Write in the employer’s name, address, and company phone number.

In addition, write the date in which the injury occurred and the location of the accident. In the Average Gross Earnings per week line, fill in the amount of what you earn from your employer, including overtime and bonuses.

Injury Information Section

If you had an accident, this section is where you will provide concise information regarding your injury. Give details regarding every part of your body that was injured. You also need to be very specific regarding how the injury occurred including any physical changes that you experienced.

If you were involved in a slip and fall accident that caused a knee injury, you don’t want to just say that you tripped. You want to describe the environment and how the accident occurred. So, for example, you would write that your foot struck a piece of broken concrete on the floor in a dimly lit warehouse room that resulted in you falling down on your left leg, which caused your dislocated knee.

Occupational Disease Information Section

You may be diagnosed with an occupational disease — such as lung disease, skin disease, lead poisoning, or others — which can be directly linked to the type of work that you performed. If you are seeking to claim benefits for this occupational disease, you can complete this section. Provide details about the occupational disease, the date when you last worked for the employer, and the name of the doctor who told you that the occupational disease was caused by your work.

Request for Benefits

This section is a series of checkboxes, check each box that applies to you in order to formally notify the Virginia Workers Compensation Commission and the insurance carrier specifically which of benefits you are requesting.  Typically, everyone needs to request a Lifetime Medical Award. There are several types of benefits you may be able to receive based on the severity of your injuries and specific circumstances: lost wages, unpaid medical bills, amputations, and death benefits for a surviving spouse. You can also complete this form if you have been previously denied benefits. These are the benefits you may request on the Claims Form:

Lifetime Medical Benefits: You can receive lifetime compensation or reimbursement benefits for prescriptions, out-of-pocket medical treatments, and transportation costs that have already been paid for or treatments that will be paid for in the future.

Full Wage Loss Benefits: You can fill in the amount of time that you missed work and receive wage compensation if didn’t receive full wages during the stated time period. If you continue to be out of work, you would state  “and continuing” for the end date.

Lower Earned Wages Benefits: You can receive partial wage loss compensation if you continue to work, but earn less that your pre-injury average weekly wage.

Permanent Partial/Total Disability Benefits: You can receive permanent partial or permanent total disability benefits if you lose range of motion in certain body parts, lose hearing/vision, have lung disease, or become disabled due to a severe brain injury or are paralyzed.

Unpaid Medical Bills Benefits: You can request payment for out-of-pocket expenses for medical bills, prescription medications, or transportation costs related to medical treatments for an injury.

Death Benefits: Family members of the deceased worker can receive death benefits to pay for funeral expenses or dependents can receive up to 500 weeks of benefits.

Other Benefits: You can use this line to request benefits if there are changes to your injury, such as a temporary disability becoming a permanent disability, a rise in the cost of living expenses, or the injury/occupational disease leads to death.

Once you have marked the appropriate checkboxes, you will need to sign and date the Claim Form.

Signature and Date Lines

Ensure you sign and date your name at the bottom of the Claim Form. Include the date that you filled out the form.

Other Documents

After completing the Claim Form, you will need to send it to the Workers’ Compensation Commission along with all medical records, receipts and itemized bills related to your injury that support your requests. If there is any form that you cannot get from a doctor, you can file a subpoena against the medical provider through the Commission by paying a $12.00 (money order) fee.

Filling out the Virginia Worker’s Claim Form will allow you to obtain compensation and reimbursement for the accident. If you have any problems filling out the form, getting advice from our workers’ compensation attorneys can make the process easier.

Video Transcript

In this presentation, we will explain how to fill out a Claim Form for a workers compensation claim.

Since each case is different, I strongly advise you to have an attorney fill out your Claim Form or, at the very least, review the claim with you so that your benefits are protected.

When you get a Claim Form, which you can download from our website, or from the Virginia Workers Compensation Commission website, you will see that there are two parts, part A and Part B.

Make sure you fill out part A completely, be sure you include your name and employer’s contact information.

The next most important section is labeled parts of your body injured. Here you list all of your body parts effected by the injury. It is important to list all effected body parts, even the minor injuries, as the insurance company is not legally responsible to cover the cost of the injury if the body part is not listed. When in doubt, listing the body part is the best idea.

In this section, it is your opportunity to give a detailed description on how the injury occurred. Remember, being injured by lifting boxes all day or slipping somehow are not covered injuries, you MUST be specific with a specific time and specific event.

For example, while I was lifting the third bucket of paint to the shelf I felt a sharp pain in my lower back or I slipped and fell because I was not able to see the wet floor since I was carrying a large box.

In this section you need to fill in the date of the injury and your average weekly wage. Make sure that you include overtime and bonuses into your average weekly wage amount.
If you are slightly off on the wage amount don’t worry, a 52 week wage statement will be created from your pay stubs and the weekly wage amount will get adjusted.

If you’re on the insurance adjuster, make sure that your overtime, bonuses and possible shift differentials are added. Also remember, if you have a second similar job, the wages from that work can also be added, so if you are a waitress in two different restaurants you can list all wages. However, if you are a waitress and a cook, those jobs are not similar and do not add to your average weekly wage.

Remember to sign and date the Claim Form form at the end of part A.

In part B, you will specify what it is that you are requesting. Even though the form say optional, we strongly suggest that you fill out this section. At a minimum you want to request lifetime medical benefits, so be sure to check that box.

In the lost wages section you need to add the dates that you have lost a full day of work. If you are still out of work, then you need to list the first date, than add until present and continuing.

If you are only able to work 4 hours each day, then you need to ask for partial lost wages by checking the third box and giving specific dates.

By checking the 4th box, you’re asking for permanent partial disability benefits, which is the permanent loss of use of a body part. This is not something that is normally filled out right away but after a doctor states that you will not be getting any better. At that time, you would need to fill out an additional form requesting permanent partial disability benefits at that time.

You would check box 5 if doctors or medical providers are sending you copies of bills requesting payment.

Box 6 is for requesting death benefits

And “other” would be for requesting specific things, like approval for an MRI or other such items.

Lastly, you need to attach your medical records, any itemized bills and receipts, or your out of work disability slips. If these items are not attached with your request, your claim will be filed and put on hold by the Commission until additional medical records are received.

Filing a claim is a slow process, so if you can help speed things up by supplying all the needed information right from the beginning, there is a better chance of your claim being processed quickly.

Once you have filed your completed claim form with the Virginia Workers Compensation Commission, you will receive a copy of the 20 Day Order request, that is generated by the Commission to the insurance carrier which gives them 20 days to legally either accept or deny the claim. If the claim is denied they will have to give specific reasons why the claim is being denied.

If the claim is accepted, you will have to sign agreement forms sent to you by the insurance company and, once the adjuster is able to submit them to the Commission, the Commission will issue an Award Order and you’ll be protected.

The Injured Workers Law Firm is focused on serving clients with workers’ compensation claims throughout Virginia.For answers to your questions about benefits download our book, The Ultimate Guide to Workers’ Compensation in Virginia or call our office today (804) 755-7755. The Injured Workers Law Firm, serving Fredericksburg, Virginia Beach, Manassas, Charlottesville, Fairfax, Hampton Roads and all of Virginia.