Wv workers compensation form employers 2025

1. Click ‘Get Form’ to open the West Virginia Workers’ Compensation Employers’ Report of Occupational Injury or Disease in the editor.
2. Begin with Section I by entering your Employer Information. Fill in details such as Insurer, Third-Party Administrator, Employer’s Name, Nature of Business, FEIN, and Address including City, State, and Zip.
3. Proceed to Section II for Employee Information. Input the employee's Name (Last and First), Occupation/Job Title, Address, Telephone number, Date of Birth, Sex, and check applicable boxes regarding their employment status.
4. In Section III, provide detailed information regarding the Injury or Disease. Include the Date of Injury or Last Exposure, Time of injury occurrence, Witnesses to the injury, and a description of what the employee was doing at that time.
5. Complete Section IV by detailing Wage and Lost Time Information. Enter Last Day Worked After Occupational Injury or Disease and Date of Return to Work along with Number of Work Days Lost.
6. Finally, certify your statements by printing your name, signing the form with your title and date before submitting it.

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