TEMPLATE

West Virginia incident report template

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Your West Virginia incident report has 5 rules to meet. ReportDraft puts every one on your checklist and checks your draft before you sign.

  • Every injury: the report to the carrier within 5 days of the employee's notice
  • The statement on whether you dispute compensability or temporary total disability
  • The employee's written notice: names, time, place, nature, cause, time off

An incident report template set up for West Virginia, with fields for the employee's written notice of injury received (date), has temporary total disability resulted (off work)?, report sent to the carrier or claims administrator (date) and employer's statement on the report. In Word and PDF.

See a free preview filled from sample notes

REPORTDRAFT.COM
West Virginia Incident report Template
Company or organization
Site address or location
Date of the incident
Type of incident
Completed by
Employee's written notice of injury received (date)
Has temporary total disability resulted (off work)?
Report sent to the carrier or claims administrator (date)
Download in Word or PDFIncluded with ReportDraft Safety and its free trial.

West Virginia rules for this report

These rules are about how and when you report, not the template's fields. Check them before you deliver.

  • Every employer reports every injury of anyone in its employ to its workers' compensation insurance carrier or claims administrator, on the Insurance Commissioner's forms, within five days of receiving the employee's notice of injuryW. Va. Code 23-4-1b
  • The carrier or claims administrator cannot extend the five-day period, but the employer may file a supplemental report laterW. Va. Code 23-4-1b
  • The employer's report states whether, on the information available, the employer disputes the compensability of the injury or objects to paying temporary total disability benefits; the statement does not stop the employer contesting the claim laterW. Va. Code 23-4-1b
  • A late report, or a statement that the employer does not dispute the claim, waives the employer's right to object to interim temporary total disability payments from the date of injury until the insurer receives an objectionW. Va. Code 23-4-1b
  • The injured employee gives the employer or its agent written notice immediately or as soon as practicable, stating in ordinary language the employer's and employee's names and addresses, the time, place, nature and cause of the injury, and whether temporary total disability has resulted; given in person or by certified mailW. Va. Code 23-4-1a
  • The employee's application for compensation is filed on the Insurance Commissioner's forms with the Commissioner, private carrier or self-insured employer within six months after the injury or death, or the right is barredW. Va. Code 23-4-15 (a)

What is in it

  • What happenedWhat the person was doing just before the incident, with the tools, equipment or material used, then how the incident happened, in the order it happened.
  • Injury or illness and treatmentThe part of the body affected and how, the object or substance that directly caused harm, and the first aid or medical treatment given and where.
  • Damage to property, equipment or the environmentWhat was damaged, spilled or released, and how much, as the notes give it.
  • Immediate actions takenWhat was done right away: first aid, emergency calls, the area made safe, equipment stopped or tagged out, and who was notified.
  • CausesThe immediate cause and any underlying causes the notes identify: equipment, procedures, training, work conditions, supervision. Only what the notes support.
  • Witness statementsName, Role, What they saw or said
  • Corrective actionsAction, Responsible, Due, Status

Rules last reviewed October 15, 2026. Read the full West Virginia incident report requirements.