Get Va Vwc Pneumoconiosis Claim Form 2019-2025

Filling out the VA VWC Pneumoconiosis Claim Form is an important step in seeking benefits for coal workers' pneumoconiosis. This guide provides a clear, step-by-step approach to help users complete the form online with confidence.

Follow the steps to successfully complete your claim form.

1. Click the ‘Get Form’ button to access the claim form and open it for editing.
2. Fill in your personal information as the injured worker. This includes your name, primary and alternate phone numbers, and your complete address including city, state, and zip code.
3. Proceed to Part A, where you will provide employer information. Include the name of the company, county of work location, the company's address, city, state, and zip code. Also, fill in the date of communication, last date worked, and date of x-ray.
4. Indicate the last employer for whom you worked 90 shifts prior to communication. You will be prompted to answer whether you have worked after the date of communication by selecting 'Yes' or 'No.' If you answer 'Yes,' please indicate the name of the employer.
5. Sign and print your name in the designated area, confirming that you are filing this claim to protect your rights under the Virginia Workers' Compensation Act.
6. If you are seeking specific benefits or if your claim has been denied, complete Part B by indicating the types of benefits you are requesting, including compensation for permanent loss, reimbursement for medical bills, or other benefits.
7. Review all entries for accuracy and completeness. Ensure all required fields are filled out before finalizing the form.
8. Once you are satisfied with the entries, you can save your changes, download a copy of the form, print it, or share it as needed.

Complete your VA VWC Pneumoconiosis Claim Form online today and ensure your rights to benefits are protected.