Report Of Minor Injuries {45-A}

Report of Minor Injuries Submit to: Virginia Workers Compensation Commission 45 - A 100 DMV Drive Richmond VA 23220 See instructions on the reverse of this form. Insurer Name of insurer or self-insurer Period covered From / / To / / . Address Insurer code Insurer location Date filed Contact Person Phone number Payments NOTE: If this accident has been previously reported on Form 45A, place an X in the box by the entry. Name of employee Social Security Number Date of accident Address of employee Name and address of employer Employer Tax Identification Number Monthly medical cost Name of employee Social Security Number Date of accident Address of employee Name and address of employer Employer Tax Identification Number Monthly medical cost Name of employee Social Security Number Date of accident Address of employee Name and address of employer Employer Tax Identification Number Monthly medical cost Name of employee Social Security Number Date of accident Address of employee Name and address of employer Employer Tax Identification Number Monthly medical cost Name of employee Social Security Number Date of accident Address of employee Name and address of employer Employer Tax Identification Number Monthly medical cost Name of employee Social Security Number Date of accident Address of employee Name and address of employer Employer Tax Identification Number Monthly medical cost Name of employee Social Security Number Date of accident Address of employee Name and address of employer Employer Tax Identification Number Monthly medical cost Report of Minor Injuries VWC Form No. 45A (rev. 9/1/99) <<<<<<<<<********>>>>>>>>>>>>> 2 INSTRUCTIONS Report of Minor Injuries VWC Form No. 45A 1. This form is to be used to report minor injuries which do not: (a) result in lost time of more than seven days; (b) involve more than $1,000 in medical costs; or (c) involve any fatality, permanent disability, or disfigurement.* The information you provide is used both to report on medical costs and to provide proper notification to injured employees of their rights under the Virginia Workers Compensation Act. 2. Please type or print all information in black ink. All the information listed is required. Please make sure that social security number and accident date are provided for all employees, that the federal tax identification number is provided for all employers. Please place a check in the box to the left of employees name whenever the accident has been previously reported to the Commission as a Minor Injury Claim. If this is the first report for a particular case, and there has been no medical cost, place a zero ($ 0) in the box for monthly medical cost. Be sure to include all the insurer information at the top of the form. 3. Additional copies of this form are available without cost by writing to the Commission. Please note that any alternate versions of the form you develop require prior approval. Write to Forms at the listed Virginia Workers Compensation Commission address. 4. If you are interested in electronic transmission of this information, and have not previously discussed the issue with the Commission, please send a letter to Information Systems Department at the Virginia Workers Compensation Commission. Please provide a brief indication of your current data processing and communication capabilities, and the name and phone number of the person in your organization who should be contacted about such issues. __________________________________ *More specifically, the seven situations in which you should NOT use this form, and should instead file an Employers First Report of Accident are when (1) lost time exceeds seven days, (2) medical expenses exceed $1,000, (3) compensability is denied, (4) issues are disputed, (5) the accident resulted in death, (6) permanent disability or disfigurement may be involved, and (7) a specific request is made by the Virginia Workers Compensation Commission.