VWC Forms

VWC Form Relevant to
ADR Mediator Evaluation Form
  • Injured Workers
  • Claim Administrators
  • Attorneys
  • Employers
  • Insurers
  • Medical Providers
Amputation Chart - Foot (Form 7)
  • Injured Workers
  • Claim Administrators
  • Attorneys
  • Employers
  • Insurers
  • Self-Insureds
  • Medical Providers
Amputation Chart - Hand (Form 7)
  • Injured Workers
  • Claim Administrators
  • Attorneys
  • Employers
  • Insurers
  • Self-Insureds
  • Medical Providers
Annual Payroll Report of City, Town or County Operating as a Self-Insurer (Form 26C)
  • Self-Insureds
Annual Report of Premiums, Assessments, Etc., Received by Insurance Carriers (Form 26A)
  • Insurers
Annual Report of Self-Insurer's Payroll (Form 26)
  • Self-Insureds
Annual Report of Self-Insurer's Payroll by City, Town or County School Boards (Form 26b)
  • Self-Insureds
Application for Individual Self-Insurance (Form 20)
  • Self-Insureds
Attending Physician Report (Form 6)
  • Injured Workers
  • Claim Administrators
  • Attorneys
  • Insurers
  • Self-Insureds
  • Medical Providers
Award Agreement
  • Injured Workers
  • Claim Administrators
  • Attorneys
  • Employers
  • Insurers
  • Self-Insureds
  • Medical Providers
Certificate of Service
  • Attorneys
Certificate of Workers' Compensation Insurance (Form 61A)
  • Employers
Certificate of Workers' Compensation Insurance (Form 61A) - ONLINE
  • Employers
Change In Condition Claims Response Form
  • Injured Workers
  • Attorneys
  • Medical Providers
Claim for Benefits Form
  • Injured Workers
  • Attorneys
Claimant's Affidavit
  • Attorneys
COLA Request Form (CA51)
  • Injured Workers
  • Claim Administrators
  • Attorneys
  • Employers
  • Insurers
  • Self-Insureds
Electronic Claims Administrator Address List
  • Claim Administrators
Electronic Trading Partner Agreement Form
  • Claim Administrators
Electronic Trading Partner Profile
  • Claim Administrators
Electronic Transmission Profile
  • Claim Administrators
Employer's Application for Hearing (Form 5A)
  • Claim Administrators
  • Attorneys
  • Employers
  • Insurers
  • Self-Insureds
Expedited Hearing Request Form
  • Injured Workers
  • Attorneys
Fatal Award Agreement
  • Injured Workers
  • Claim Administrators
  • Attorneys
  • Employers
  • Insurers
  • Self-Insureds
Fatal SSA Verification
  • Injured Workers
  • Claim Administrators
  • Attorneys
  • Employers
  • Insurers
  • Self-Insureds
First Report of Injury
  • Claim Administrators
GSIA Application
  • GSIAs
Informational Letter Where Employee IS NOT Represented by Counsel
  • Attorneys
Letter for Beneficiary in Fatal Case
  • Attorneys
Letter of Credit
  • Self-Insureds
Letter to Sheriff
  • Attorneys
Mediation Consent Form A - All Parties Have Legal Counsel
  • Injured Workers
  • Claim Administrators
  • Attorneys
  • Employers
  • Insurers
  • Self-Insureds
  • Medical Providers
Mediation Consent Form B - All Parties Do Not Have Legal Counsel
  • Injured Workers
  • Claim Administrators
  • Attorneys
  • Employers
  • Insurers
  • Self-Insureds
  • Medical Providers
Mediation Request Form
  • Injured Workers
  • Attorneys
  • Employers
Medical Care Provider Application Response Form
  • Injured Workers
  • Claim Administrators
  • Attorneys
  • Employers
Medical Provider Inquiry
  • Medical Providers
Notice Terminating Prior Rejection of Coverage (Form 17A)
  • Employers
  • Insurers
Notice Terminating Prior Rejection of Coverage (Form 17A) - ONLINE
  • Employers
Parental Guarantee (Form 22)
  • Self-Insureds
PEO Access Form
  • PEOs
  • WebFile
PEO Parental Guarantee
  • PEOs
Petition Under Virginia Birth-Related Neurological Injury Act (Form BR1)
  • Attorneys
Pre-Hearing Motions Order
  • Injured Workers
  • Attorneys
Pre-Hearing Statement Order - Claimant's Claim
  • Attorneys
Pre-Hearing Statement Order - Claimants Claim and Employers Application
  • Attorneys
Pre-Hearing Statement Order - Employer's Application
  • Attorneys
Pre-Hearing Statement Order - Medical Care Provider's Application
  • Attorneys
Referral for Lack of Coverage
  • Employers
Referral for Lack of Coverage - ONLINE
  • Employers
Rejection of Coverage (Form 16A)
  • Employers
  • Insurers
Rejection of Coverage (Form 16A) - ONLINE
  • Employers
  • Insurers
Sample Affidavit
  • Injured Workers
  • Attorneys
Sample Informational Letter
  • Injured Workers
  • Attorneys
Sample Order
  • Attorneys
Sample-Informational-Letter-Fatal-Case
  • Injured Workers
  • Attorneys
Self Insurance Survey - Commercial (Form 23A)
  • Self-Insureds
Self-Insurance Bond (Form 21A)
  • Self-Insureds
Self-Insurance Survey - Government (Form 23B)
  • Self-Insureds
Subpoena Duces Tecum - Attorney Issued
  • Attorneys
Subpoena Duces Tecum - Requesting Party
  • Attorneys
Subpoena Duces Tecum - VWC Issued
  • Attorneys
Subpoena for the Taking of Deposition
  • Attorneys
Termination of Wage Loss Award Form
  • Injured Workers
  • Claim Administrators
  • Attorneys
  • Employers
  • Insurers
  • Self-Insureds
Wage Chart (Form 7A)
  • Claim Administrators
  • Attorneys
  • Employers
  • Insurers
  • Self-Insureds
Waiver of Occupational Disease (Form 9A)
  • Employers
WebFile Attorney Registration Form
  • Attorneys
  • WebFile
Witness Subpoena - Attorney Issued
  • Attorneys
Witness Subpoena - VWC Issued
  • Attorneys