VWC Forms

VWC Formsort ascending
Witness Subpoena - Attorney Issued
WebFile Attorney Registration Form
Waiver of Occupational Disease (Form 9A)
Wage Chart (Form 7A)
Transportation/Travel Expense Form
Termination of Wage Loss Award Form
Subpoena Duces Tecum - Attorney Issued
Self-Insurance Bond (Form 21A)
Sample Order
Sample Informational Letter
Sample Affidavit
Request for Issue Mediation
Request for Full and Final Mediation
Rejection of Coverage (Form 16A) - ONLINE
Rejection of Coverage (Form 16A)
Referral for Lack of Coverage - ONLINE
Referral for Lack of Coverage
Pre-Mediation Statement Form (Contested Original Claim)
Pre-Mediation Statement Form (All Claims)
Pre Mediation Statement Form (Awarded Claim)
Pneumoconiosis Claim Form
Petition Under Virginia Birth-Related Neurological Injury Act (Form BR1)
PEO Parental Guarantee
PEO Access Form
Parental Guarantee (Form 22)
Notice Terminating Prior Rejection of Coverage (Form 17A) - ONLINE
Notice Terminating Prior Rejection of Coverage (Form 17A)
Medical Provider Inquiry
Medical Fee Schedule Dispute Response Form
Medical Fee Schedule Dispute Request Form
Medical Care Provider Application Response Form
Mediation Consent Form B - All Parties Do Not Have Legal Counsel
Mediation Consent Form A - All Parties Have Legal Counsel
Marketing/Job Search Form
Letter of Credit
Letter for Beneficiary in Fatal Case
Informational Letter where Employee is NOT Represented by Counsel
GSIA Application
First Report of Injury
Fatal Award Agreement
Expedited Hearing Request Form
Employer's Application for Hearing (Form 5A)
Electronic Transmission Profile
Electronic Trading Partner Profile
Electronic Trading Partner Agreement Form
Electronic Claims Administrator Address List
Detailed Claims Addendum for Claims in Excess of $100000
COLA Request Form (CA51)
Claim Summary Addendum for 2021 Annual Survey
Claim Summary Addendum for 2019 Annual Survey
Claim Form
Change In Condition Claims Response Form
Certificate of Workers' Compensation Insurance (Form 61A) - ONLINE
Certificate of Workers' Compensation Insurance (Form 61A)
Certificate of Service
Award Agreement
Attending Physician's Report (Form 6)
Application for Individual Self-Insurance (Form 20)
Annual Report of Self-Insurer's Payroll by City, Town or County School Boards (Form 26B)
Annual Report of Self-Insurer's Payroll (Form 26)
Annual Report of Premiums, Assessments, Etc., Received by Insurance Carriers (Form 26A)
Annual Payroll Report of City, Town or County Operating as a Self-Insurer (Form 26C)
Amputation Chart
ADR Mediator Evaluation Form