Fillable Vwc Form 3 - Employer'S Accident Report (Page 2 of 2) in pdf

FILING INSTRUCTIONS

(Instructions Updated 09/01/07)

Employer’s Accident Report

VWC Form No. 3

This form must be completed by the employer, the employer’s representative or the insurer and filed within 10 days after the

notice of a work-related injury, occupational illness/disease or if the occurrence resulted in death to the worker. If the employer or

its representative completed the form, the form should be submitted to the insurer who provided insurance coverage on the date of

the occurrence, and the insurer will immediately file the original and one copy of the completed form with the Virginia Workers’

Compensation Commission, 1000 DMV Drive, Richmond, VA 23220. The additional copy of the Employer’s Accident Report

(VWC Form No. 3) will be furnished to the Virginia Department of Labor and Industry. The filing of this form with the

Commission is a requirement under §65.2-900 of the Act.

Employer

1. As the employer, you are responsible for accurately completing all sections of this form when one of your

employees is injured. It should be typed or legibly printed, signed, and dated by the preparer. Your insurance

carrier, claims servicing agency, self-insured employer’s representative or third-party administrator should

complete the information in the top right corner.

2. The “trading as” or “doing business” as name should appear in Block l and the Parent Corporation (policy named

insured) should be reflected in Block 6.

the insurance information (name, address, policy number, and effective date of the policy), that covers the

Provide

date that the work-related accident or occupational illness or disease occurred, in Blocks 8, 9 and 10.

4. As the employer, if you are subject to OSHA record-keeping requirements, a copy of this completed form may be

retained as a supplementary record of an occupational illness or disease. Use Block 3 (Employer’s Case No.) to

cross-reference any master-log of work-related accidents, illnesses, diseases and death claims.

5. Send the original beige form to your insurance carrier, claims servicing agency, or third-party administrator for

processing.

Insurance Companies, Self-Insurers, Servicing Companies, Authorized Representatives, Third-Party Administrators

(TPA’s), Group Self-Insurance Associations, and Professional Employer Organizations (PEO’s):

The insurer should provide the information at the top right of the form. Use a numerical code (1-7) to indicate the

reason for filing the form for accidents meeting one of the filing criteria’s*. When using a code reason (7) provide

the VWC file number. Note that the insurer code refers to the five-digit numeric code assigned by the National

Counsel on Compensation Insurance (NCCI). The Virginia Workers’ Compensation Commission assigns self-

insured employers a similar five-digit code number. Professional Employer Organizations (PEO’s) must use the

VWC reference number.

2. If the work-related accident or occupational illness or disease does not meet one of the filing criteria*, a Report of

Minor Injuries (VWC Form 45-A) should be completed for the occurrence and timely filed with the Virginia

Workers’ Compensation Commission.

3. Verify the insurance information that was provided by the employer (name, address, policy number, and effective

date of the policy) as it appears on this form and ensure that it covers the date that the accident or occupational

illness or disease occurred (Blocks 8, 9 and 10).

4. Provide the applicable information requested in Blocks 50 through 58 as it applies.

Forms: Additional copies of this form are available without cost by writing to the Commission. Address your inquiries to

“Forms” at the listed Virginia Workers’ Compensation Commission address. This form is also available on the

Commission’s website, at Note: color-coding of the forms greatly increases the Commission’s

efficiency in processing claims, and that any alternative versions of the form you develop yourself require prior approval by

the Commission. The original copy of the Employer’s Accident Report (VWC Form No. 3) should be on beige paper.

Electronic Filing: The Employer’s Accident Report (VWC Form No. 3) can be filed electronically through the

Commission’s Website, at

For questions or assistance regarding the electronic filing process, please

contact our “Information Systems Department” at (804) 367-2254 or in writing. Also, provide a brief description of your

current data processing and communication capabilities.

For questions or assistance with completing the form, please contact the First Report’s Unit at (804) 367-0072 or the

Commission’s Toll-free number at (1-877) 664-2566.

*The criteria’s for filing are (1) lost time exceeds seven days, (2) medical expenses exceed $1,000, (3) compensability is denied, (4) issues are

disputed, (5) 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.

Vwc Form 3 - Employer'S Accident Report Page 2

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