Get Va Vwc Pneumoconiosis Claim Form 2019-2025

Completing the VA VWC Pneumoconiosis Claim Form online is a crucial step for individuals seeking benefits for coal workers' pneumoconiosis. This guide provides clear, step-by-step instructions to help you navigate each section of the form with confidence.

Follow the steps to successfully complete the claim form.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Fill in your injured worker information. Include your name, primary phone and alternate phone numbers, address, city, state, and zip code.
3. Complete Part A by providing your employer information. Include the name of the company, county of work location, address, city, state, zip code, date of communication, last date worked, and date of the X-ray reading used as evidence.
4. Indicate the last employer for whom you worked 90 shifts prior to the communication of diagnosis. Specify if you worked after this communication date by selecting 'Yes' or 'No' and provide the name of the employer if applicable.
5. Sign and print your name in the signature field, along with the date, to confirm that you are filing this claim for benefits under the Virginia Workers’ Compensation Act.
6. In Part B, if you need assistance obtaining specific benefits, check the appropriate boxes for compensation requests and provide any necessary details, including the claim jurisdiction number if already awarded.
7. Once all sections are completed, make sure to save your changes, and choose to download, print, or share the form as needed.

Take action now and complete your VA VWC Pneumoconiosis Claim Form online to ensure you receive the necessary benefits.