WV Form OIC-WC-1, the Employees’ and Physicians’ Report of Occupational Injury or Disease, is the document that starts a West Virginia workers’ compensation claim. You fill out the top half describing the injury, your initial treating provider fills out the bottom half with the medical findings, and the completed form goes to your employer’s workers’ compensation carrier within six months of the injury date. Form OIC-WC-1 is yours; your employer files a separate form, OIC-WC-2.
Give Your Employer Written Notice First
Before the form, there is a notice. West Virginia Code 23-4-1a requires you to notify your employer, or any of the employer’s agents, as soon as the injury happens or as soon as practicable afterward. Put the notice in writing. Include your name and address, your employer’s name and address, the time and place of the injury, what caused it, and whether you’ve missed any work.
You can hand-deliver the notice or send it by certified mail to the employer’s last known address. Mail a copy to the Workers’ Compensation Commission as well. This written notice starts your employer’s own five-day clock to file their report under West Virginia Code 23-4-1b, so doing it promptly protects your benefits timeline.1West Virginia Legislature. West Virginia Code 23-4-1B – Report of Injuries by Employers
Filling Out Section I: The Employee Portion
Section I is labeled “All Information Must Be Completed by Injured Employee.” Every field needs an answer. Blanks slow the claim down or get the form sent back.2West Virginia Offices of the Insurance Commissioner. Employees’ and Physicians’ Report of Occupational Injury or Disease – Form WC-1
- Personal details: full legal name, Social Security number, marital status, sex, date of birth, home address with county, and phone number.
- Injury date and time, plus the time you started your shift that day. For occupational diseases, use the date of last exposure.
- The date and time you actually stopped working because of the injury.
- Every body part affected. Be specific. Write “left shoulder,” not “shoulder.”
- A plain-language description of how the injury happened, what you were doing, and any equipment or objects involved. Get this right. Vague descriptions give the carrier room to question the claim.
- Your job title and a short description of the role you were performing.
- Whether the injury happened on the employer’s property, and the exact address where it occurred.
- Your employer’s name, address, county, phone number, and your supervisor’s name.
- If you work for a government entity, a box indicating whether you want to use accrued sick leave or draw temporary total disability benefits. County Board of Education employees also complete a separate County Board Option Form.
You sign a certification at the bottom of Section I attesting that everything you’ve written is true. The certification cites West Virginia Code 61-3-24f and the criminal penalties that apply if you knowingly withhold facts or make false statements to get benefits you aren’t entitled to.
Section II: What Your Doctor Fills In
Section II is labeled “All Information Must Be Completed By Initial Provider.” Your job is to get the form in front of that provider, usually the first doctor, hospital, or clinic that treats the injury. Bring it to your first appointment, or confirm that the carrier has forwarded it.3West Virginia Department of Transportation. West Virginia Form OIC-WC-1 – Employees’ and Physicians’ Report of Occupational Injury or Disease
The provider records:
- Their name, FEIN or Social Security number, address, and phone number.
- The date of initial treatment and the estimated date you can return to work.
- Whether they’ve advised you to stay off work for four or more days, with specific dates, plus any modified-duty restrictions if you can return in a limited capacity.
- Whether the condition is an occupational injury, an occupational disease, or non-occupational.
- Whether this injury aggravated a pre-existing condition, with an explanation.
- A medical description of the injury, the body parts affected, and ICD diagnosis codes in order of severity.
- The name of any physician you were referred to, and the hospital name if you were admitted.
The physician signs their own certification. It warns of penalties under West Virginia Code 61-3-24g for false reports or helping anyone obtain undeserved benefits, and it authorizes release of office notes and test results to the employer or their representative.
Where to Send It and By When
The completed form goes to your employer’s workers’ compensation insurance carrier. You can download OIC-WC-1 from the West Virginia Offices of the Insurance Commissioner website. Private carriers sometimes issue their own branded version with the mailing address pre-printed, though carriers cannot alter the employee fields without prior approval from the Insurance Commissioner.4West Virginia Offices of the Insurance Commissioner. Workers’ Compensation Forms If your employer handed you a copy, it likely already shows the correct insurer address.
The deadline is printed on the form: to be eligible for benefits, your claim must be filed within six months from the date of the injury or death.2West Virginia Offices of the Insurance Commissioner. Employees’ and Physicians’ Report of Occupational Injury or Disease – Form WC-1 File well before that date. A last-minute submission leaves no room to correct errors or round up missing medical records, and the longer the gap between the injury and the filing, the easier it is for the carrier to argue the injury isn’t really work-related.
Keep a copy of everything you submit. Note the date you sent it. If you mail the form, use certified mail so you have proof of delivery.
After You File
The claims administrator at the carrier reviews your report and the medical documentation. The carrier must act on the claim within 15 working days and may issue a conditional approval if more information is needed. You, your employer, and any attorney on record receive a written decision on whether the claim is compensable.
If the claim is approved, you’ll be assigned a claim number to use for all future correspondence, including medical appointments, benefit payments, and any legal proceedings. If the claim is denied or you disagree with the decision, you have 60 days from the date of the notice to file a protest. Miss that window and the decision becomes final.
If 14 days pass after you send the form and you’ve heard nothing back, contact the Workers’ Compensation Commission directly.2West Virginia Offices of the Insurance Commissioner. Employees’ and Physicians’ Report of Occupational Injury or Disease – Form WC-1
What an Approved Claim Covers
An approved OIC-WC-1 opens access to several categories of benefits.
Medical Care
West Virginia pays for health care services, durable medical equipment, and related supplies reasonably required to treat the work injury. You get to choose your initial treating physician. If you later want to change providers and your employer participates in a managed care program, your replacement must come from inside that network.
Temporary Total Disability
If the injury keeps you off work, temporary total disability benefits replace part of your lost wages. Under West Virginia Code 23-4-6, the TTD rate is two-thirds of either your daily rate of pay on the date of injury or your average weekly wage based on the best quarter of the four quarters before the injury, whichever amount is higher. TTD benefits cannot exceed 100 percent of the state’s average weekly wage.
Benefits don’t start on day one. You must be disabled for at least three consecutive calendar days before TTD begins. If your disability runs more than seven consecutive days, the first three days get paid retroactively. The maximum TTD period is 104 cumulative weeks.
Permanent Disability
If your doctor determines you have a lasting impairment after you reach maximum medical improvement, you may be evaluated for permanent partial disability or, in the most serious cases, permanent total disability benefits. The evaluation is performed by a physician selected by the insurance carrier or self-insured employer.
The Fraud Warning Is Real
The certifications on OIC-WC-1 are not boilerplate. Employees who knowingly withhold facts or make false statements to obtain or increase benefits face criminal penalties under West Virginia Code 61-3-24f. Physicians who certify false reports or help someone secure undeserved benefits face separate penalties under 61-3-24g.2West Virginia Offices of the Insurance Commissioner. Employees’ and Physicians’ Report of Occupational Injury or Disease – Form WC-1 Be accurate and thorough in Section I, and make sure your physician has complete information before signing Section II.