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The document is an Amputation Chart used by the Virginia Workers' Compensation Commission, containing fields for recording details related to an employee's amputation claim, including personal information of the employee and employer, accident details, and medical documentation.

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Click ‘Get Form’ to open the Amputation Chart in the editor.
Begin by entering the VWC file number in the designated box. This is essential for tracking your claim.
Fill in the insurer code and location, ensuring accuracy to avoid any processing delays.
Next, input the insurer claim number along with the employer's name and details of the employee involved.
Provide the date of accident and select which foot was affected by marking it clearly in the appropriate section.
Finally, include your signature, along with the date and details from a medical doctor (M.D.) regarding the amputation.

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