Pneumoconiosis Claim Form


Va. Code § 65.2-400 defines occupational disease as a “disease arising out of and in the course of employment, but not an ordinary disease of life to which the general public is exposed outside of employment.” When an individual has received a communication of diagnosis of occupational disease, it is important to give immediate notice to the employer.

If you wish to assert your rights, Part A of the Claim Form should be completed and returned. If specific benefits are being requested, or if your claim has been denied, Part A and Part B of the Claim Form should be completed and returned with supporting medical records to the Commission as soon as possible. Va. Code § 65.2-406 provides that a claim must be filed “For coal workers’ pneumoconiosis, three years after a diagnosis of the disease, as category 1/0 or greater as classified under the current International Labour Office Classification of Radiographs of the Pneumoconiosis, is first communicated to the employee or the legal representative of his estate or within five years from the date of the last injurious exposure in employment, whichever first occurs.”


This form may be filed with the Commission in the following ways:

  • ONLINE: WebFile users may upload this form through their account. Click here to learn more about WebFile.
  • FAX: Fax the complete form to 804-823-6956.
  • MAIL: Mail the completed form to 333 E. Franklin St., Richmond, VA 23219.
  • IN PERSON: Bring the completed form to any of our VWC Office Locations.

For questions, please contact the Commission toll-free at 1-877-664-2566 or by email at