Form 45a - Report Of Minor Injuries
Download a blank fillable Form 45a - Report Of Minor Injuries in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 45a - Report Of Minor Injuries with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Report of Minor Injuries
Submit to:
Virginia Workers’ Compensation Commission
45 - A
1000 DMV Drive Richmond VA 23220
See instructions on the reverse of this form.
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, pl ace an “X” 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 Injuries
VWC Form No. 45A (rev. 9/1/99)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 8wc - Employer's First Report Of Occupational Injury Or Disease - The State Of New Hampshire, Department Of Labor
Legal
Form 5020 - Employer's Report Of Occupational Injury Or Illness/form Dwc 1 - Workers' Compensation Claim Form
Business
Related Categories
Parent category: Legal