General Instructions For Completing The Wc-1, "Employees' And Physicians' Report Of Injury" printable pdf download

General Instructions for Completing the

WC-1, “Employees’ and Physicians’ Report of Injury”

- Please Read Carefully -

General Overview: The claim initiation process now involves the filing of two individual forms:

: To be completed by the injured employee and the medical provider.

WC-1, Employees’ and Physicians’ Report of Injury

WC-3, Employers’ Report of Injury: To be completed by the employer

A claim cannot be established until the Workers’ Compensation Commission has received at least one of the forms listed above. This

form should not be used to file occupational pneumoconiosis or hearing loss claims.

Please note that W.V. Code 23-4-1 provides that employees of the state and its political subdivisions are ineligible to receive workers’

compensation benefits while drawing sick leave benefits at the same time for the same reason. You must make your choice known

in Question 13 of this form.

To the Injured Worker: Section I of this form must be completed by you. When you have completed this form, make a copy for

your records, and make a copy to give to your employer. The initial medical provider is responsible for completing Section II of

this form, and your employer is responsible for completing the WC-3, Employers’ Report of Injury. Both the provider and employer

will be required to send the signed completed forms to the Commission. If you do not receive a decision on your claim within 14 days

after sending the form, contact Workers’ Compensation Commission. The responsibility of filing a claim rests with you. To be

eligible for benefits, your claim must be filed with the Commission within six months from and after the injury or death. If you

1-800-231-4850 or visit our Web site at

have any questions, you may contact the Commission at

To the Initial Medical Provider: Section II of this form must be completed by you. The timely provision of information regarding

the injured worker’s condition is vital in deciding eligibility for benefits. Each answer should be as specific as possible. You should

immediately send a copy of all records, office notes, and test results regarding the injured worker’s exam to Workers’ Compensation

Commission. After completing this form, please make two copies – one for your records and one for the injured worker to take

to the employer. Your office is responsible for sending the signed original form to the Workers’ Compensation Commission. If

1-800-628-4265 or visit our Web site at

you have any questions, you may contact Workers’ Compensation Commission at

Section I

Question

Number

Explanation

This date is defined as either the date you were injured or the date you were last exposed if you are filing an

occupational disease claim.

List part(s) of body injured.

Your description of how the injury occurred is reviewed to determine eligibility for benefits.

10.

Describe the job you are currently working. If you are a state, municipal, or county employee, you need to include that

in the information. (i.e. construction workers for the state.)

13.

According to the Workers' Compensation Temporary Total Disability Benefits/Sick Leave Policy, if you are absent

from work due to a work-related injury, you must choose to receive either Temporary Total Disability benefits (TTD

benefits) from Workers' Compensation or paid sick leave. If you elect to receive TTD benefits, you may use sick leave

until you receive your initial TTD benefit check; however, this leave will be restored when you reimburse your

employer the net value of the paid sick leave used, according to the provisions of this policy.

Section II

Question

Number

Explanation

Federal Identification Number or Social Security Number and name, facility or group name you report to Workers’

Compensation Commission for billing purposes.

In your opinion, was the patient injured at work, exposed to a disease at work, or is the condition not work related?

7a.

Define injury. (i.e., sprain/strain, fracture, laceration)

7b.

Part(s) of body injured.

7c.

How injury occurred. (i.e., lifting, fall, motor vehicle accident)

Describe in detail what effect, if any, the patient’s previous health may have on this injury.

Please mail the completed form to: Workers’ Compensation Commission

P. O. Box 431

Charleston, WV 25322-0431

When completing this form, enclose attachments if additional space is needed.

General Instructions For Completing The Wc-1, "Employees' And Physicians' Report Of Injury"

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