Report of Minor Injuries Submit to: 45 - A Virginia Workers’ Compensation Commission 1000 DMV Drive Richmond VA 23220 See instructions on the reverse of this form. Insurer Name of insurer or self-insurer Period covered From Address Insurer code / / Insurer location Contact Person To / / . Date filed Phone number Payments NOTE: If this accident has been previously reported on Form 45A, pl ace an “X” in the box by the entry. Name of employee Social Security Number Address of employee Date of accident 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) American LegalNet, Inc. www.FormsWorkflow.com FILING INSTRUCTIONS (Instructions Updated 09/01/07) Report of Minor Injuries VWC Form No. 45A 1. This form is 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 a fatality, permanent disability, or disfigurement.* The information you provide is used both to report on medical costs and provides proper notification to injured employees of their rights under the Virginia Workers’ Compensation Act. 2. The insurer should provide the information at the top of the form and the Report of Minor Injuries (VWC Form No. 45A) should be submitted to the Commission on a monthly basis. 3. Type or legibly print all information on the form for each employee including, the social security number, accident date and the federal tax identification number for all employers. 4. Place a check in the box to the left of the employee’s name whenever the accident has been previously reported to the Commission as a Minor Injury Claim and additional medical costs were incurred, but the total medical costs have not exceeded $1,000. 5. If this is the initial reporting of a claim, and there has been no medical cost, place a zero ($0) in the box for monthly medical costs. It is not necessary to report zero ($0) medical costs each month after the initial reporting of the injury. 6. Forms: Additional copies of this form are available without cost by writing to the Commission. Address your inquiry to “Forms” at the listed Virginia Workers’ Compensation Commission address. Please note that any alternate versions of the form you develop yourself require prior approval by the Commission. 7. Electronic Filing: The Report of Minor Injuries (VWC Form No. 45A) can be filed electronically through the Commission’s website, www.vwc.state.va.us and selecting “Electronic Filing Services”. If you are interested in the batch processing method, please contact our “Information Systems Department” at (804) 367-2084 or in writing. Please provide a brief description of your current data processing and communication capabilities. 8. For questions or assistance with completing this form, please contact the First Reports Unit at (804) 367-0072 or the Commission’s toll free number (1-877) 664-2566. __________________________________ *More specifically, the seven situations in which you should NOT use this form, and should instead file an Employer’s Accident Report 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. American LegalNet, Inc. www.FormsWorkflow.com