The Virginia Claim for Benefits, also called VWC Form #5, is the form an injured worker files with the Virginia Workers’ Compensation Commission to protect their right to medical care and lost wages after a work injury. If you got hurt on the job in Virginia, this one-page form (Part A and Part B, Rev. 11/09) is the document that puts your case on record and stops the clock on the state’s strict deadline.
Filing the wrong way, or missing the deadline, can cost you everything. Under Va. Code §65.2-601, you have just two years from the date of injury to file, and the Commission reports that late or incomplete claims are among the top reasons benefits get delayed or denied. Get this form right, and you lock in your rights even if your employer’s insurer has been paying you so far.
- 🩹 How to complete Part A and Part B of VWC Form #5 line by line, with sample entries
- 📋 The exact documents and numbers to gather before you open the form
- 💻 How to file by WebFile, fax, mail, or in person — with addresses, fees, and proof to keep
- ⚠️ The field-level mistakes that quietly sink claims, like leaving out an injured body part
- ❓ Plain-English answers to the questions injured workers ask most
What the Claim for Benefits Form Is and Who Must File It
The Claim for Benefits form is the official request that opens or protects your workers’ compensation case in Virginia. It tells the Virginia Workers’ Compensation Commission (the VWC) who you are, who you worked for, how you got hurt, and what help you need. Without this form on file, the Commission has no record of your claim, even if your employer knows you were injured.
You must file this form if you were hurt at work or developed an occupational disease on the job in Virginia. This is true even if your employer or its insurance company has already paid some of your medical bills or lost wages. Those voluntary payments do not protect your legal rights. Only a filed claim does that.
The statute behind this form is Va. Code §65.2-601, which requires a claim for benefits within two years of the injury. The plain-English version is simple: if you do not file in time, your right to benefits dies, no matter how badly you were hurt. The consequence of ignoring this rule is permanent — a worker who waits 25 months loses the case before it starts. A common misconception is that getting paid by the insurer “counts” as filing; it does not, and many workers learn this only after the deadline passes.
Most filers are injured workers acting on their own, called pro se filers. Attorneys, spouses, or other family members may also file on the worker’s behalf. The form is written for stressed people who may be out of work and worried about money, so the steps below keep things calm and clear.
Before You Start: Documents and Information You Need
Filling out the form goes faster and cleaner when you gather everything first. Each item below has a reason, and missing one can slow or weaken your claim.
- Your full legal name and current address. The Commission mails decisions here, so a wrong address means missed deadlines.
- Your home and work phone numbers. Claims staff and the insurer use these to reach you about exams and hearings.
- Your employer’s exact legal name, address, and phone. The wrong employer name can attach your claim to the wrong insurer and stall everything.
- The date of injury (or date of diagnosis for a disease). This date starts the two-year clock under §65.2-601, so it must be exact.
- A list of every body part you hurt. Body parts you leave off are usually not covered later, even if they were injured in the same accident.
- Your average gross weekly earnings. This number, including overtime and bonuses, sets the dollar value of your wage checks.
- The city or county and state where the accident happened. This sets the Commission’s jurisdiction over your case.
- Your medical records and itemized bills. Records that link the injury to work are the proof the Commission needs to approve benefits.
- Dates you missed work or earned less pay. These dates support your wage-loss request in Part B.
- For an occupational disease, the disease name and key dates. You need the date you last worked there and the date a doctor linked the disease to your job.
If you cannot get your medical records, the Filing Instructions let you ask the Clerk for a subpoena. You must mail the provider’s name and address plus a $12.00 money order payable to the Sheriff of the city or county where the provider sits. The Commission cannot issue subpoenas outside Virginia.
Where to Get the Form and How to Access It
You get the Claim for Benefits form straight from the source so you know it is current. Download the official PDF from the VWC Claim Form page, which hosts VWC Form #5. The version in use carries the revision date Rev. 11/09 in the corner, so check that you have that one.
You can also file the claim through the Commission’s online system. The WebFile for Claimants portal lets you create an account, view your claim activity, see which claim administrator handles your case, and submit the Claim for Benefits without printing anything. WebFile is the Commission’s preferred channel because it date-stamps your filing right away.
If you cannot print or go online, call the Commission toll-free at 1-877-664-2566 or email Questions@workcomp.virginia.gov to ask how to get a paper copy. Staff can also answer questions while you fill it out. The form is one page, with Part A on the front and Part B plus the filing instructions and a benefits list on the reverse side.
A common misconception is that any blank workers’ comp form found online will do. It will not. Outdated or out-of-state forms can be rejected or routed wrong, so always pull the current Virginia PDF from the agency itself.
Step-by-Step: How to Fill Out VWC Form #5 Line by Line
The form has two parts. Part A is required for every filer. Part B is optional and used only when you want the Commission to act on specific benefits. Work top to bottom and use ink or type so entries stay readable. Sample entries below are shown in italics.
Jurisdiction Claim # and Claim Administrator
The top of the form asks for the Jurisdiction Claim # and the Claim Administrator #. In plain English, these are case numbers the Commission and the insurer assign to track your file. To answer, write these numbers only if you already have them from a prior notice or letter; if this is your first filing, leave them blank.
For example, Darnell Pierce, filing for the first time after a fall, leaves both number lines empty because no case exists yet. The edge case is a worker who already got a letter from the insurer — that letter often lists the Claim Administrator # and it should be copied in exactly.
A common mistake is guessing or inventing a number to fill the space, which can attach your form to someone else’s file. The direct consequence is a misrouted claim and weeks of delay. The misconception here is that these fields are required; they are not, and a blank is correct for new filers.
Injured Worker’s Name
This field asks for your full legal name. Write it the way it appears on your government ID and Social Security card, last name and first name, so the Commission can match you across records. Print clearly in all caps if your handwriting is hard to read.
For example, MARIA SANTOS writes her full legal name, not a nickname like “Mia.” The edge case is a recent name change after marriage or divorce — use the name on your current ID and note the prior name in Part B “Other” if records still carry it.
A common mistake is using a nickname or initials, which can break the link between your claim and your medical and wage records. The consequence is a processing hold while staff confirm your identity. The misconception is that the name “everyone calls you” is fine; the Commission needs your legal name.
Address, City, State, Zip
This block asks where you live now. Enter your current mailing address, city, state, and ZIP code, because the Commission mails orders, hearing notices, and decisions to this exact spot. Use the address where you actually receive mail.
For example, Maria Santos writes 4127 Grove Ave, Richmond, VA 23221. The edge case is a P.O. Box — that is allowed for mail, but add a physical address in Part B “Other” if a process server may need to find you.
A common mistake is listing an old address after a move. The consequence is brutal: you can miss a hearing notice and lose by default. The misconception is that the Commission will track you down by phone or email; it relies on the mailing address you provide.
Home Phone and Work Phone
These fields ask for the best numbers to reach you. Enter a working home or cell number and a work number if you have one, including area code, so claims staff and the insurer can schedule exams and calls. A cell number is fine in the home phone line.
For example, Maria Santos writes (804) 555-0193 for home and leaves the work phone blank because she is out on injury. The edge case is having no landline — a mobile number in either field is acceptable.
A common mistake is leaving both phone lines empty. The consequence is missed scheduling calls that can be read as a lack of cooperation. The misconception is that the Commission only writes letters; phone contact is common and useful, especially around medical exams.
Employer’s Name, Address, City, State, Zip, and Phone
This block asks who you worked for when you got hurt. Enter your employer’s full legal business name, full address, and phone number, because this is how the Commission identifies the right insurer to defend and pay the claim. Use the legal name on your pay stub or W-2, not a store nickname.
For example, Maria Santos writes Tidewater Logistics LLC with the warehouse address, not just “the warehouse.” The edge case is a staffing agency — list the agency that signs your paychecks, and add the worksite company in Part B “Other.”
A common mistake is naming a parent company or a brand instead of the legal employer. The consequence is a claim sent to the wrong insurer and a fight over who is responsible. The misconception is that the address of the store you worked at is enough; the Commission needs the employer’s official business address.
Parts of Your Body Injured
This is one of the most important fields on the form. It asks you to list every body part hurt in the accident. To answer, name each part plainly and fully — left, right, upper, lower — because the Commission generally covers only the body parts you list here.
For example, Maria Santos writes lower back, right shoulder, and right knee, not just “back.” The edge case is pain that spreads later, such as a back injury that causes leg numbness; if it appears after filing, you must amend your claim to add it.
A common mistake is listing only the worst injury and skipping the others. The consequence is that the insurer can deny treatment for the body parts you left out. The misconception is that “back injury” covers your whole body; it does not, and each part must be named.
How Injury Occurred
This field asks for a short story of what happened. Write a clear, factual description of the event — what you were doing, what went wrong, and how you got hurt — because Virginia law requires an injury by accident arising out of and in the course of employment. Keep it specific and true.
For example, Maria Santos writes While lifting a 60-pound box onto a shelf on 03/14/2026, I felt a sudden pop in my lower back and fell, twisting my right knee. The edge case is a gradual or repetitive injury, which may not qualify as an accident and may instead need the occupational disease section.
A common mistake is writing something vague like “my back hurts at work.” The consequence is the insurer arguing there was no sudden accident, a common reason for denial. The misconception is that any work pain is automatically covered; Virginia requires a specific accident or a recognized disease.
Date of Injury
This field asks when the accident happened. Enter the exact calendar date in MM/DD/YYYY format, because this date starts your two-year filing deadline under §65.2-601 and anchors your wage calculation. If you are unsure, use the date the accident occurred, not the date you saw a doctor.
For example, Maria Santos writes 03/14/2026. The edge case is an occupational disease, where you use the diagnosis date instead, since a disease has no single accident date.
A common mistake is entering the date you reported the injury or first saw a doctor instead of the accident date. The consequence is a wrong deadline calculation that can make a timely claim look late. The misconception is that the dates are interchangeable; for an accident, only the injury date counts.
Average Gross Earnings per Week
This field sets the money value of your wage benefits. Enter your average gross weekly pay before taxes, and include overtime, bonuses, tips, and the value of regular extras, because Virginia bases wage checks on your full pre-injury earnings. Add up roughly 52 weeks of gross pay and divide by the weeks worked.
For example, Maria Santos earned $48,000 in the prior year with overtime, so she writes $923.08 per week. The edge case is a worker employed less than a year — use the actual weeks worked to find the average.
A common mistake is writing take-home pay or leaving out overtime. The consequence is a permanently lower benefit check, since this number drives your compensation rate. The misconception is that “gross” means your base hourly wage only; it means total earnings, extras included.
Location of Accident (City or County) and State
This field asks where the accident physically happened. Enter the city or county and the state where you were hurt, because this sets the Commission’s authority over your claim. Use the work location, not your home.
For example, Maria Santos writes Chesapeake and VA. The edge case is a traveling worker hurt in another state — Virginia may still have jurisdiction if you were hired or normally work in Virginia, so list the actual accident location and explain in Part B.
A common mistake is leaving this blank or entering the company headquarters in another city. The consequence is a jurisdiction dispute that delays the case. The misconception is that the employer’s main office location controls; the place the accident happened is what matters here.
Injured Worker’s Signature, Print Name, and Date
This is the block that makes the claim official. Sign your name on the Injured Worker’s Signature (Required) line, print your name next to it, and enter the date you sign, because an unsigned form is not a valid claim. The signature also confirms the language above it: that you file this claim to protect your rights and, unless Part B is marked, you are not yet asking for specific action.
For example, Maria Santos signs in cursive, prints MARIA SANTOS, and dates it 03/20/2026. The edge case is filing for a worker who cannot sign — a spouse, attorney, or guardian may sign and should note their role in Part B “Other.”
A common mistake is forgetting to sign or to date the form. The consequence is the most avoidable one possible: the Commission can reject an unsigned claim, and if the deadline passes meanwhile, the claim is lost. The misconception is that typing your name in WebFile is not a “real” signature; an electronic submission through your own account counts.
Part B – Request for Benefits (Optional Checkboxes)
Part B is where you tell the Commission what help you want. Check each box that applies, because leaving Part B blank means you filed only a protective claim and asked for no specific action yet. The header reads “I need assistance obtaining the following benefits and request a hearing if necessary.”
The boxes are: – Lifetime Award of medical benefits for your injury, including treatment already received and paid. – I missed work because of my injury for the periods From / To (two date lines). – I earned less pay while at work because of my injury for the periods From / To (two date lines). – Loss of use or amputation of a body part, loss of hearing/vision, lung disease, or bodily scarring/disfigurement. – Unpaid medical bills or out-of-pocket medical, prescription, or transportation expenses. – Death benefits to dependents or funeral expenses. – Other, such as Change in Condition or Permanent Total Disability.
For example, Maria Santos checks the lifetime medical box and the “missed work” box, writing From 03/15/2026 To present. The edge case is not knowing your return date — write to present or continuing.
A common mistake is checking a box but not attaching the proof. Boxes marked with ** require you to attach medical records, itemized bills, or receipts. The consequence of skipping proof is a delayed or denied request. The misconception is that checking a box alone wins the benefit; the Commission needs medical and financial evidence behind each one.
Occupational Disease Section
The bottom of Part B handles diseases instead of accidents. If you are claiming an occupational disease, fill the three lines: the name of the occupational disease, the date you last worked for this employer, and the date a doctor told you the disease was caused by work. These dates set the deadline and prove the work link.
For example, Robert Chen, a painter with chemical-related lung disease, writes occupational asthma, 02/10/2026, and 02/24/2026. The edge case is a slow disease diagnosed long after exposure — the diagnosis date, not the first exposure, generally starts your clock.
A common mistake is leaving the doctor’s causation date blank. The consequence is the insurer arguing the disease is not work-related. The misconception is that disease claims work like accident claims; they use these special dates and almost always need a doctor’s written opinion.
Three Filled-Out Examples Using Real Scenarios
Below are three common ways Virginia workers complete VWC Form #5, each followed start to finish.
Scenario 1 — Maria Santos, warehouse back injury requesting medical plus lost wages. Maria lifted a heavy box, hurt her back, shoulder, and knee, and has been out of work since.
| Form Section | What Maria Enters |
|---|---|
| Injured Worker’s Name | MARIA SANTOS |
| Address | 4127 Grove Ave, Richmond, VA 23221 |
| Employer’s Name | Tidewater Logistics LLC |
| Parts of Your Body Injured | Lower back, right shoulder, right knee |
| How injury occurred | Lifting a 60-lb box, felt a pop and fell |
| Date of Injury | 03/14/2026 |
| Average Gross Earnings per week | $923.08 |
| Location of accident | Chesapeake, VA |
| Part B boxes checked | Lifetime medical; Missed work From 03/15/2026 To present |
| Signature / Date | Maria Santos / 03/20/2026 |
Scenario 2 — Darnell Pierce, protective claim to beat the deadline. Darnell hurt his wrist, the insurer is paying voluntarily, and he files Part A only to protect his rights before the two-year deadline.
| Form Section | What Darnell Enters |
|---|---|
| Injured Worker’s Name | DARNELL PIERCE |
| Address | 88 Maple Ct, Roanoke, VA 24016 |
| Employer’s Name | Blue Ridge Contracting Inc. |
| Parts of Your Body Injured | Left wrist |
| How injury occurred | Slipped on wet stairs and caught fall with left hand |
| Date of Injury | 07/02/2024 |
| Average Gross Earnings per week | $1,050.00 |
| Location of accident | Roanoke, VA |
| Part B boxes checked | None — protective filing only |
| Signature / Date | Darnell Pierce / 06/01/2026 |
Scenario 3 — Robert Chen, occupational disease claim. Robert, a painter, developed work-related asthma and uses the disease section.
| Form Section | What Robert Enters |
|---|---|
| Injured Worker’s Name | ROBERT CHEN |
| Address | 215 Bayview Rd, Norfolk, VA 23503 |
| Employer’s Name | Coastal Painting Services LLC |
| Parts of Your Body Injured | Lungs / respiratory system |
| How injury occurred | Daily exposure to paint solvents and fumes |
| Date of Injury | Use diagnosis date 02/24/2026 |
| Average Gross Earnings per week | $880.00 |
| Occupational disease name | Occupational asthma |
| Date last worked / doctor causation date | 02/10/2026 / 02/24/2026 |
| Signature / Date | Robert Chen / 02/28/2026 |
A fourth filer, Aisha Bell, a nurse with a needlestick injury, would list right hand and check the “unpaid medical bills” box while attaching receipts. A fifth filer, Frank DiNardo, a roofer who lost two fingers, would check the “loss of use or amputation” box and attach his surgical records.
How to File the Completed Form
The Commission accepts the Claim for Benefits four ways, and you should keep proof of whichever you use. File within two years of your injury or diagnosis to stay safe under §65.2-601.
- Online (preferred): Upload through your account on the WebFile for Claimants portal. There is no fee. Filing is recorded instantly; processing is the fastest of the four channels. Save the confirmation screen and any email receipt as proof.
- Fax: Send the completed form to 804-823-6956. There is no Commission fee, though your fax service may charge. Keep the fax confirmation sheet showing the date, time, and “OK” status as proof.
- Mail: Send to 333 E. Franklin St., Richmond, VA 23219. No fee applies. Mail processing takes longer, so send it early; use certified mail with return receipt and keep the green card as proof of the filing date.
- In person: Bring the form to any VWC office location. No fee. Ask the clerk to date-stamp a copy for you and keep that stamped copy as proof.
If you need a subpoena for medical records, mail the provider’s name and address plus a $12.00 money order payable to the Sheriff of the provider’s city or county to the Clerk of the Commission. Pay nothing else to file the claim itself — the form is free through every channel.
What Happens After You File
Once your claim is on file, the Commission assigns a Jurisdiction Claim # and notifies the employer’s insurer, called the claim administrator. The insurer must respond, either accepting the claim or denying it. You can track this activity through your WebFile account.
If you completed only Part A, your claim sits protected and no hearing is set until you request specific benefits in Part B. If you checked Part B boxes and the insurer disputes them, the Commission schedules the case for a hearing before a Deputy Commissioner. You will receive notices by mail at the address you listed, which is why a correct address matters so much.
Medical records drive the outcome. The Commission needs records showing your injury or disease is work-related, so file them with the claim or as soon as you can. A common misconception is that filing the form alone proves your case; it opens the case, but evidence wins it. Decisions can be appealed within the Commission and then to the Court of Appeals of Virginia.
Mistakes to Avoid When Filling Out the Form
Each error below has cost real workers their benefits. Watch for these as you complete VWC Form #5.
- Missing the two-year deadline. Your right to benefits ends under §65.2-601.
- Listing only one injured body part. Untreated parts you left off can be denied later.
- Forgetting to sign or date the form. The Commission can reject an unsigned claim outright.
- Using a nickname instead of your legal name. It breaks the match to your wage and medical records.
- Entering an old mailing address. You can miss a hearing notice and lose by default.
- Writing take-home pay instead of gross earnings. It lowers your weekly benefit check for good.
- Naming a brand or parent company, not the legal employer. The claim goes to the wrong insurer.
- Describing the injury too vaguely. The insurer argues there was no compensable accident.
- Checking Part B boxes without attaching proof. The benefit request stalls or is denied.
- Assuming insurer payments protect your rights. Voluntary payments do not replace a filed claim.
- Leaving the occupational disease dates blank. The insurer disputes the work connection.
- Inventing a Jurisdiction or Claim Administrator number. Your form can be misrouted to another file.
Do’s and Don’ts
Do’s – Do file within two years of the injury date, because the deadline is strict and unforgiving. – Do list every injured body part, because coverage usually follows what you write here. – Do include overtime and bonuses in your weekly earnings, because they raise your benefit rate. – Do attach medical records for every Part B box you check, because evidence proves the claim. – Do keep proof of filing, because you may need to show the exact date later. – Do update your address with the Commission, because notices go only to the address on file.
Don’ts – Don’t rely on insurer payments to protect you, because only a filed claim does that. – Don’t guess your earnings, because a wrong number can lower your checks permanently. – Don’t leave Part A unsigned, because an unsigned form is not a valid claim. – Don’t use an outdated form, because a wrong version can be rejected or misrouted. – Don’t describe the accident vaguely, because the insurer will use vagueness to deny. – Don’t ignore the occupational disease lines if a disease applies, because those dates are required.
Pros and Cons of Filing on Your Own vs. With Help
Many workers file VWC Form #5 alone, while others hire a workers’ compensation attorney. Here is how the two paths compare.
| Filing Pro Se (On Your Own) | Filing With an Attorney |
|---|---|
| Pro: No legal fee, so you keep all benefits. | Pro: A lawyer spots benefits you may miss, so awards can be larger. |
| Pro: You control the filing and timing yourself. | Pro: They handle hearings and evidence, easing your stress. |
| Pro: Simple, accepted claims rarely need a lawyer. | Pro: They calculate your average weekly wage correctly. |
| Pro: WebFile makes self-filing fast and free. | Pro: They meet deadlines and procedural rules for you. |
| Pro: You learn your own case in detail. | Pro: Most work on contingency, so no upfront cost. |
| Con: Easy to miss a body part or a deadline. | Con: A contingency fee, often around 20%, comes out of your award. |
| Con: Wage math errors can lower your checks. | Con: You give up some day-to-day control of the case. |
| Con: Hearings are stressful without guidance. | Con: Good attorneys may be busy or selective. |
| Con: No one double-checks your evidence. | Con: Communication can feel slower through an office. |
| Con: Mistakes can be hard to fix after filing. | Con: Not every simple claim needs the added cost. |
Frequently Asked Questions
Is the Claim for Benefits the same as VWC Form #5? Yes. The Claim for Benefits and VWC Form #5 are the same one-page document, with Part A on the front and Part B on the reverse, filed with the Virginia Workers’ Compensation Commission.
Do I have to fill out Part B? No. Part B is optional. Completing only Part A files a protective claim that guards your deadline without yet requesting specific benefits or a hearing.
Do I write my gross pay or take-home pay in the earnings box? Yes, use gross pay. Enter your average gross weekly earnings before taxes, including overtime and bonuses, because this number sets your benefit rate.
Do I list only my worst injury under “Parts of Your Body Injured”? No. List every body part hurt in the accident, because the Commission generally covers only the parts you name on the form.
Do I use the accident date or the doctor visit date in the Date of Injury box? No, not the doctor date. Use the actual accident date, because that date starts your two-year deadline and sets your wage calculation.
Is there a deadline to file? Yes. Under §65.2-601, you must file within two years of the injury or disease diagnosis, or you lose your right to benefits.
Do insurer payments protect my rights without filing? No. Voluntary payments by your employer or insurer do not protect your claim. You must still file the form to preserve your rights.
Is there a fee to file the form? No. Filing the Claim for Benefits is free by WebFile, fax, mail, or in person. Only a records subpoena costs $12.00.
Can I file online? Yes. Use the WebFile for Claimants portal to submit the form, track your claim, and get an instant date-stamp.
Do I need a lawyer to file? No. Many workers file alone, especially for simple claims, though an attorney can help with disputed claims, wage math, and hearings.
Do I have to attach medical records? Yes, when you check Part B boxes marked with two asterisks. Those benefits require attached medical records, itemized bills, or receipts as proof.
Do I leave the Jurisdiction Claim # blank if I am filing for the first time? Yes. Leave that field blank when no case exists yet, because guessing a number can misroute your form to another worker’s file.
Can someone else sign the form for me? Yes, if you cannot sign. A spouse, attorney, or guardian may sign on your behalf and should note their role in the Part B “Other” line.
Do occupational disease claims use the same dates as accident claims? No. Disease claims use the diagnosis date, the date you last worked, and the date a doctor linked the disease to your job.
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