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First Report of Injury

Virginia Workers’ Compensation Commission 1000 DMV Drive Richmond Virginia 23220 1-877-664-2566

SEE INSTRUCTIONS ON REVERSE SIDE

Reason for filing: VWC Jurisdiction Claim #: (If assigned)

WWw.Vwe.state.va.us Claim Administrator File#:

| Employer |

Employer's Legal Name

Federal Employer Identification Number (FEIN)

Employer's Mailing Address

Name/FEIN of Entity on Policy

Nature of Business

Name and Address of Insurer or Self-Insurer for this Claim

Policy Number

| Time and Place of Accident |

Location where accident occurred Date of injury

Hour of injury

Date injury or illness reported

If fatal, give date of death

If fatal, give number of dependent children

Olam. If fatal, give marital status 0 Single O1_sDivorced OO Maried O1_ Widowed

| Injured Worker |

Name of Injured Worker

Phone Number

Injured Worker ID Number

Injured Worker's mailing address

Type of ID 1 Social Security No. Os Employment Visa O Green Card 0 sPassport No.

01 Unknown

Occupation at time of injury or illness

Date of birth

Sex

O Male O Female

| Nature and Cause of Accident

Machine, tool, or object causing injury or illness

Describe fully how injury or illness occurred

Describe nature of injury, occupational disease, or illness, including body parts affected

[Signatures |

Submitter (name, signature, title)

Date

Phone number

Submitter’s Address

VWC Form #3 Rev. 10/08