West Virginia Claim Forms
EMPLOYERS West Virginia Claim Kit (click here to download)
West Virginia Required Postings & Forms
Please post the following notices in a conspicuous location frequented by employees such as the break room, lunchroom or time clock. If you have multiple office locations be sure to post the notices at each location.
- Workers’ Compensation Insurance Notice
- Anti-Fraud Notice (English and Spanish)
- Hospital Emergency Worksite Poster
Please print and review the following forms with your current staff and new employees (at the time of hire):
The following forms need to be completed and submitted to EMPLOYERS when a work-related injury occurs:
- First Report of Injury (FROI) – Form OIC-WC-2. As soon as you have been notified of a work-related injury, please immediately fill out this form and submit it to EMPLOYERS and provide a copy to the employee. Please use this form to notify EMPLOYERS of every work-related injury or disease suffered by an employee, regardless of severity.
- Wage Statement. This form enables us to calculate the correct compensation that may be owed to your injured employee. Please complete the form and submit it to EMPLOYERS within five days after your knowledge of any accident that has caused your employee to be disabled for more than three scheduled work days.
- First Fill Form. This form provides your employees with basic information about our Pharmacy Benefit Program, including such things as the phone number to call to locate a First Fill participating pharmacy. When your employee becomes injured, please print and complete this form and provide it to your injured employee. Your employee will need to provide this completed form along with the prescription for his/her work-related injury or illness to the pharmacist. Using this form will help enable quick authorization for your employee’s initial medication and ensure that the initial prescription is provided at no cost to the injured employee.
- Accident Investigation Report. This basic accident form should be completed by the employee’s supervisor/manager as soon as possible after the accident. Please send the report to the following EMPLOYERS address as soon as it has been completed by the supervisor/manager: EMPLOYERS Claim Department, P.O. Box 32036, Lakeland, FL 33802-2036. You should keep a copy on file for your records.
Please print and provide the following items when an employee becomes injured:
- Channeling Letter. This document directs the injured employee where to go for treatment after an injury and to find a provider.
The following item is to be used as a reference document only.
- EMPLOYERS West Virginia Managed Care Program Guide. This document explains important information about the EMPLOYERS West Virginia Managed Care (EMP WV MHCP) program and the required notices.
- Off-Site Transitional Duty Program - Helping Your Injured Employees Get Back to Work
A successful transition back to work relies on the collaborative efforts of the manager/supervisor, the injured employee and their adjuster. As a manager/supervisor, learn what you can do to help facilitate a successful return to work.