VA-003A-WC free printable template

THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE WORKERS' COMPENSATION ACT. Commonwealth of Virginia Virginia Workers' Compensation Commission 1000 DMV Drive,, Richmond, Virginia 23220 VWC Claim No. SUPPLEMENTARY REPORT Case of If Employer's Accident Report did not show that the injured had returned to work, an Employer's Supplemental Report of injury should he completed and filed immediately after return to work of the employee. In the event of the death of the employee, this...report should be filed immediately. 1 Name of Employer 2 Office Address: No. and St. 3 Insured by: Name of Company 4 Name of Injured (in full) 5 Present address: No. and St. 6 Date of Injury 7 City or Town State Firs t Middle Name City or Town State Hour of Day AM or PM Date Disability began Date AM or PM 8 Has injured returned to work? If so, date and hour AM or PM 9 Is injured person earning same wages as before injury? Yes or No If not, explain 10 If...disability has not terminated, state probable date of termination of disability 11 Has injured died? Date Last Day of Week If so, date of death AM or PM NOTE: This form is not an agreement and its filing is not sufficient to terminate an outstanding award. Date of this report Firm Name Signed by Official Title VWC#3A (Rev 9/1/99)