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' Compensation 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 must be given by one or more dependents of the deceased or by a person in their behalf. 3. In case of failure to reach an agreement with the employer in regard to compensation under the act, file application with the Commission for a hearing within two years of the date of accidental injury or first communication 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 employee should file a claim with the Commission within two years from the date of the accident. NOTE: The employer's report of accident is not the filing of a claim for the employee. The voluntary payment of wages or compensation during disability, or of medical expenses, does not affect the running of the time limitation for filing claims. An award based on a voluntary agreement must be entered or a claim filed within two years; one year in death cases. THE EMPLOYER SHOULD: 1. At the time of the accident, give the employee the names of at least three physicians from which the employee may select the treating physician. 2. Report the injury to the Commission through your carrier or directly to the Commission. 3. Accurately determine the employee's average weekly wage, including overtime, meals, uniforms, etc. Questions may be answered by contacting the Commission. A booklet explaining the Workers' Compensation Act is available without cost from: THE VIRGINIA WORKERS' COMPENSATION COMMISSION 1000 DMV Drive Richmond, Virginia 23220 1-877-664-2566 vwc.state.va.us Every employer within the operation of the Virginia Workers' Compensation Act MUST POST THIS NOTICE IN A CONSPICUOUS PLACE in his place of business. American LegalNet, Inc. www.FormsWorkflow.com