Vwc Form 3 - Employers Accident Report - 2002
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1
2Reason for filing
VWC file number
Employer’s Accident Report
The boxes
(formerly: Employer’s First Report of Accident)
Insurer code or PEO Ref. No.
Insurer location
Virginia Workers’ Compensation Commission
to the right
S0225
are for the
1000 DMV Drive Richmond VA 23220
use of the
Insurer claim number
See instructions on the reverse of this form
insurer
Employer
1. Name of employer (trading as or doing business as, if applicable)
2. Federal Tax Identification Number
3. Employer’s Case No. (if applicable)
Northern Virginia Community College
4. Mailing address
5. Location (if different from mailing address)
4001 Wakefield Chapel Road, Annandale, Virginia 22003
6. Parent corporation /Policy Named Insured (if applicable) or PEO name
7. Nature of business (NAICS code, if applicable)
Commonwealth of Virginia
State Government
8. Name and Address of Insurer or self-insurer for this claim
9. Policy number
10. Effective date
DGS/DRM, PO Box 1140, Richmond, Virginia 23208
Time and Place of Accident
11. City or county where accident occurred
12. Date of injury
13. Hour of injury
14. Date of incapacity
15. Hour of incapacity
a.m.
p.m.
13a. Time began work
a.m.
p.m.
16. Was employee paid in full for day of injury?
17. Was employee paid in full for day incapacity began?
Yes
No
Yes
No
18. Date injury or illness reported
19. Person to whom reported
20. Name of other witness
21. If fatal, give date of death
Employee
22. Name of employee (Last, First, Middle)
23. Phone number
24. Sex
Male
Female
25. Address
26. Date of birth
27. Marital status
Single
Divorced
28. Social security number
Married
Widowed
29. Occupation at time of injury or illness (SOC code, if applicable)
30. Is worker covered by PEO policy?
31. Number of dependent
Yes
No
children
32. How long in current job?
33.Date of Hire
34. Was employee paid on a piece work
or hourly basis?
Piece work
Hourly
35. Hours worked
36. Days worked
37. Value of perquisites per week
Food/meals
Lodging
Tips
Other
per day
per week
38. Wages per hour
39. Earnings per week (inc. overtime)
$
$
$
$
$
$
Nature and Cause of Accident
40. Machine, tool, or object causing injury or illness
41. Specify part of machine, etc.
42. Describe fully how injury or illness occurred
43. Describe nature of injury or illness, including parts of body affected
43a. Overnight inpatient hospitalization?
Yes
No
43b. Treated in Emergency Room?
Yes
No
44. Physician (name and address)
45. Hospital or Clinic (name and address)
46. Probable length of disability
47. Has employee returned
If
48. At what wage?
49. On what date?
yes
to work?
Yes
No
50. EMPLOYER: prepared by (name, signature, title)
51. Date
52. Phone number
53. INSURER: (name of processor)
54. Date
55. Phone number
56. THIRD PARTY ADMINISTRATOR (if applicable)
57. Address
58. Phone number
This report is required by the Virginia Workers’ Compensation Act
Employer’s Accident Report
VWC Form No. 3 (rev. 03/22/02)
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Parent category: Business