VWC Forms

VWC Form
ADR Mediator Evaluation Form
Amputation Chart
Annual Payroll Report of City, Town or County Operating as a Self-Insurer (Form 26C)
Annual Report of Premiums, Assessments, Etc., Received by Insurance Carriers (Form 26A)
Annual Report of Self-Insurer's Payroll (Form 26)
Annual Report of Self-Insurer's Payroll by City, Town or County School Boards (Form 26B)
Application for Individual Self-Insurance (Form 20)
Attending Physician's Report (Form 6)
Award Agreement
Certificate of Service
Certificate of Workers' Compensation Insurance (Form 61A)
Certificate of Workers' Compensation Insurance (Form 61A) - ONLINE
Change In Condition Claims Response Form
Claim Form
Claim Summary Addendum for 2019 Annual Survey
COLA Request Form (CA51)
Detailed Claims Addendum for Claims in Excess of $100000
Electronic Claims Administrator Address List
Electronic Trading Partner Agreement Form
Electronic Trading Partner Profile
Electronic Transmission Profile
Employer's Application for Hearing (Form 5A)
Expedited Hearing Request Form
Fatal Award Agreement
First Report of Injury
GSIA Application
Letter for Beneficiary in Fatal Case
Letter of Credit
Marketing/Job Search Form
Mediation Consent Form A - All Parties Have Legal Counsel
Mediation Consent Form B - All Parties Do Not Have Legal Counsel
Medical Care Provider Application Response Form
Medical Fee Schedule Dispute Request Form
Medical Fee Schedule Dispute Response Form
Medical Provider Inquiry
Notice Terminating Prior Rejection of Coverage (Form 17A)
Notice Terminating Prior Rejection of Coverage (Form 17A) - ONLINE
Parental Guarantee (Form 22)
PEO Access Form
PEO Parental Guarantee
Petition Under Virginia Birth-Related Neurological Injury Act (Form BR1)
Pneumoconiosis Claim Form
Referral for Lack of Coverage
Referral for Lack of Coverage - ONLINE
Rejection of Coverage (Form 16A)
Rejection of Coverage (Form 16A) - ONLINE
Request for Full and Final Mediation
Request for Issue Mediation
Sample Affidavit
Sample Informational Letter
Sample Order
Self Insurance Survey - Commercial (Form 23A)
Self-Insurance Bond (Form 21A)
Self-Insurance Survey - Government (Form 23B)
Subpoena Duces Tecum - Attorney Issued
Termination of Wage Loss Award Form
Transportation/Travel Expense Form
Wage Chart (Form 7A)
Waiver of Occupational Disease (Form 9A)
WebFile Attorney Registration Form
Witness Subpoena - Attorney Issued