Workers' Compensation Notice for the Commonwealth of Virginia Mandatory

Form VWC1 	
WORKERS'
 COMPENSATION NOTICE	
                                                                        \
     
The employees of this business are covered by the Virginia Workers' Compensation Act.  In case of injury by accident or 
notice of an occupational disease: 
   THE EMPLOYEE SHOULD:	 	
1. Immediately give notice to the employer, in writing,  of the injury or occupational disease and the date of
accident or notice of the occupational disease.
2. Promptly give to the employer and to the  Virginia Workers' Com	 pensation Commission notice of any
claim for compensation for the period of disability beyond  the seventh day after the accident.  In case of fatal
injuries, notice m ust be given by one or more depende nts of the deceased or by a person in their behalf.	
3. In case of failure to reach an agreement with th e employ	 er in regard to compensation under the act, file
application  with the Commission for a hearing within tw o years of the date of accidental injury or first
com munication of the diagnosis of an occupational disease.	
4. If medical treatment is anticipated for more than two years from the date of the accident and no award has
been entered, the em ploy	
ee should file a claim with the Commission within two years from  the date of the
accident. NOTE:  Th	
e employer's report of accident is not the filin	g of a claim 	for the employee.  	
   THE EMPLOYER SHOULD:	 	
1. At the time of the accident, give the employee 
the names of at least three 	 physicians from which the
em ployee may select the treating phy sician.	
2. Report the injury to the Commission through your carrier or directly to the Commission.
3. Accurately determine the employee's average w eekly wage, including overtim	 e, meals, uniforms, etc. Questions may be answered by con
tacting the Commission.  A booklet explaining the Workers' Com p	
ensation Act is 
available without cost from: 
THE VIRGINIA WORKERS'	
  COMPENSATION COMMISSION 
333 E. Franklin St  
Richmond, Virginia 232	
 19
1-877-664-2566
www.workcomp.virginia.gov
Every	

 em ployer within the operation of the Virginia Workers' Com p	
ensation Act MUST POST THIS NOTICE IN A 
CONSPICUOUS PLACE in his place of business.