How to Fill Out the Virginia Workers’ Comp Claim for Benefits Form

If you?re hurt in a workplace accident, you must fill out the Claim Form and turn it into the Virginia Workers’ Compensation Commission. The law requires you to complete the form within two years of your accident or diagnosis to protect your right to workers’ comp benefits. Your employer might have taken responsibility and begun paying your medical bills. Or it might be fighting your claim. You should do this whether or not your claim has already been approved or denied.

If you have questions about filling out the form and asking for workers’ compensation benefits, talk with a Roanoke workers’ comp attorney at Lugar Injury Law. We have years of experience helping injured workers and surviving relatives win the benefits the law entitles them to. Call (540) 384-0348 or use the online form to set up a consultation.

Filling Out the VA Workers’ Comp Claim Form

You need to fill out each section of the Claim Form completely and accurately.

• Leave the top section blank: At the very top is a section for Jurisdiction Claim Number (JCN) and Claim Administrator Number. You don?t need to fill these in if you don?t have that information. The Virginia Workers’ Compensation Commission will add that information.
• Fill in accurate personal information: Give your full legal name, address, and phone number(s).
• Fill in your employer?s information: You also need to know your employer?s name, address, and phone number.
• Give a full description of your injury and the accident: You want to provide as much information about your injury as possible. Note each part of your body that is hurt and every physical change you?ve experienced. You must write down when and where the accident occurred. You want to be specific. For example, don?t just say you tripped. Say your foot caught on a loose cord. Provide details about what happened and why.
• Attach copies of your medical records: If you have medical records regarding your injury or diagnosis, get copies from your doctor and attach them to the form. You can turn the form in without your medical records. But you should provide copies to the Commission as soon as possible.
• Calculate your weekly average gross earnings: Gross earnings include any tips, commissions, bonuses, and payment for overtime before deductions for Social Security and other taxes. It?s not your final take-home pay. You should add up your gross earnings for the previous year (52 weeks) and divide it by 52. The answer is your weekly average. This number affects your wage benefits?it?s vital to get it right. Don?t hesitate to talk with an attorney about calculating your gross earnings.
• Requests all appropriate benefits: You should always request a Lifetime Medical Award. If you?re unable to work right now, request Temporary Total Disability. If you?re able to perform some tasks?light duty?then request Temporary Partial Disability. If you suffered an amputation, loss of the use of a body part, disfigurement, hearing or vision loss, or lung disease, check the box for Permanent Partial Disability. If you?re filling out the form after the death of a loved one, request Death Benefits.
• Attach receipts to the form: If you request reimbursement of medical bills, transportation costs, prescriptions, or other expenses related to your workplace injury, attach an itemized list of receipts. You can request reimbursement if you?ve suffered costs from the work-related injury that your employer hasn?t paid for yet.
• Sign and date the form: To complete the form, you must sign and date it.

Let a VA Workers’ Compensation Lawyer Help

Dealing with doctors, insurance companies, and government agencies is intimidating. It?s particularly troublesome when you?re in pain and recovering from serious injuries. Attorney Cerid Lugar believes in helping you through the workers’ compensation claim process. You don?t have to go it alone and hope for the best. Let Lugar Injury Law right for you to receive the full benefits you deserve. Contact us through our online form or call (540) 384-0348 to schedule a free initial consultation.