To receive workers’ compensation benefits in Virginia, you must report your on-the-job injuries in a timely fashion. Below is a sample letter you can give to your employer to satisfy the legal requirements regarding notice.

Name of Supervisor
Title
Employer Name
Address

Dear (Name of Supervisor) :

Please accept this letter as written notice that on (date) at (time) I was involved in the following work accident (give details). Immediately after the accident, I spoke with (name of person with whom you spoke) and (what happened post-accident, including medical treatment if you have obtained it). I am in the process of having my injuries evaluated. Based on my treatment regimen thus far, it is my understanding that I suffered the following injuries: (list injuries). I have received the following restrictions (list restrictions) from (doctor’s name).

I would appreciate it if you would provide a panel of physicians with whom I may treat. Due to uncertainties regarding my recovery and the type of treatment I may require in the future, it will be necessary for me to file a workers’ compensation claim. Please let me know the best way for me to file a claim with your workers’ compensation insurance carrier.

Thanks for your assistance. If you need any information fro me or wish to speak with me regarding the accident, my injuries, and my restrictions, contact me at your convenience. I look forward to working with you through this time.

Sincerely, (Your name)