FIRE/RESCUE
WORKERS
COMPENSATION
CLAIM FORMS
MUST NOTIFY MICHELLE DALTON WITHIN
24 HOURS OF ACCIDENT
ATTENDING PHYSICIAN MUST
COMPLETE FORM WHEN GOING TO
EMERGENCY ROOM OR DOCTORS
OFFICE
Virginia Association of Counties Group
Self-Insurance Association
308 Market Street, SE, Suites 1 & 2
RISK
T
Roanoke, VA 24011
540-345-8500 or Toll Free 877-212-8599
M(^E( NT
RA MS
Workers' Compensation Fax 877-212-8599
Please Print
SECTION A - (To be comDleted b Emnlovee or Supervisor)
VACoGSIA Member/Employer
VACoGSIA Member ID#
Member Phone
Employee Name (last name first)
Home Address
Home Phone
SSN
Date of Injury/Illness
/
/
Time of Injury/Accident
Location of Accident including ZIPCODE
Department
Job Title
Incident Description
y
DOB
AM or PM
Nature of Injury/Illness (including body parts affected)
Safeguards/Safety Equipment Provided? Yes 0 No D Used? Yes q No q Required? Yes q No 0
Name of Witnesses
First-Aid Treatment Administered by
Describe First-Aid Treatment
Person Injury/Illness Reported To
Date Injury Reported
/ /
Panel Provided? Yes D No q Physician/Facility Seen
H as the Employee Returned to Work: Yes q No D Modified Duty Available: Yes D No q
Comments
Supervisor Name
Phone
Supervisor Signature
SECTION B - (To be completed b y Payiroll Department)
Employer Federal Tax ID
Date Disability Began _I /
Wages Paid on Date of Injury? Yes q No 0 How Long Employed with Employer
Hours Worked per Day/Days Worked per Week/Wages per Hour
/
/
Earnings
per D Week per 0 Month per 0 Year (check one)
Name of Person Repo rting Loss
Telephone Number of Person Reporting Loss
MEDICAL AUTHORIZATION
I hereby authorize any medical care provider to furnish to Virginia Association of Counties Group Self-Insurance
Association (VACoGSIA), or its representatives, upon request, any and all information, facts, records, or "reports
relating to any advice, evaluation, treatment, diagnosis, prognosis, disability, recommendations for further care and/or
statements of causation in compliance with the Virginia Workers' Compensation Act, and to discuss with them any
such information, facts, records or reports, to be used for the evaluation and handling of my workers' compensation
claim and to assure timely medical care required by the incident occurring on or about the date noted above and for
no other purpose, now or in the future. I also agree that a photographic carbonless copy of this release shall be as 'valid
as the original.
Employee Signature
Date
rR15^KRGE ENT
Virginia Association of Counties Group
Self-Insurance Association
308 Market Street, SE, Suites 1 & 2
Roanoke, VA 24011
s
VACa G^'^
Medical Form to Be Completed by Attending Physician
Note to Physician Please Fax Completed Form to VACoGSIA at 877-212-8599
Employee Name
Employee Address
Name of Employer
Date of Accident/Injury
Date of Visit
Patient's account of how medical problem occurred
Diagnosis
New Injury/Illness: Yes
El
No q
Yes q No q
Existing Condition:
Did diagnosis result from patient's desc ribed onset: Yes q No q Unknown q
Physician comments
Work Status
Return To Work Full Duties
Return To Work Modified Duties
Yes q No q Date
Yes q No q Date
List restrictions
Att ending Physician (please print)
Phone
Physician signature
Date
Follow-up appointment with
Date Time
VACoGSIA 308 Market Street,. SE., Suites 1 & 2 Roanoke, VA 24011
Telephone: 540-345-8500 or Toll Free: 1-888-822-6772 Toll Free Fax: 877-212-8599