Member Forms and Resources

Administrative Forms

• Request a Certificate of Coverage
• Assistance with Contract Review
• Travel and Expense Reimbursement Form
• Member Contingency Fund - Deposit Form
• Member Contingency Fund - Withdrawal Form

VCJPA Coverage Program Forms

• Auto Physical Damage Claim Form
• Auto Accident Checklist
• Auto Liability coverage ID card (login required)
• Property Claim Reporting Requirements and Forms
• Property Coverage - Addition Form
• Business Travel Accident Coverage - Addition Form
• Business Travel Accident Beneficiary Cards
• Business Travel Accident ID Card (login required)
• Business Travel Accident Travel Assistance Services (login required)
• Business Travel Accident Identity Theft Services (login required)

WC Resources for Members

WC 101 Video

• COVID-19 AIMS Reporting Form
• VCJPA Quick Claims Reporting Reference
• Employer Report of Injury Form 5020
• Employee Claim Form DWC 1
• Declination of Medical Care Form
• Claim Form Receipt
• Supervisor's Accident Report Form
• Quick Reference Upon Notice of an Industrial Injury or Illness
• AMC Call Connect 24/ Nurse Triage & Injury Reporting Services
• AMC CallConnect and MPN Training Video