Claim Form

The injured worker must file a claim with the Virginia Workers’ Compensation Commission in order to protect their right to benefits under Virginia law, even if there have been payments by the employer or claim administrator for time missed from work because of the injury or for medical treatment for the injury.

Benefits Covered under the Virginia Workers’ Compensation Act:

• Lifetime Medical Benefits – Payment for medical treatment/expenses for the injury or occupational disease, now and in the future.
• Temporary Total Disability - Wage loss replacement while completely out of work. Must be medically authorized.
• Temporary Partial Disability – Wage loss replacement while partially out of work, or working light duty. Must be medically authorized.
• Permanent Partial Disability – Compensation for loss of use of a body part, amputation, disfigurement/bodily scarring, loss of hearing, loss of vision or lung disease. Must be medically supported.
• Medical Expenses – Payment/reimbursement of medical bills, or out of pocket expenses, such as prescription and mileage/transportation. Must provide bills, receipts and/or mileage logs.
• Death Benefits – Payment/reimbursement of funeral/transportation expenses or wage loss replacement for surviving spouse, children, or certain other dependents. Death certificate, Marriage License and/or Birth Certificate(s) must be provided.
• Other – Benefits not previously mentioned (vocational rehabilitation, specific medical treatment/procedure, panel of physicians, etc.).