Warren County Self Insurance

Volunteer Forms

• Claimant Information Packet: Information for people who will be making a claim
  • Claimant Information Packet (PDF)
• Volunteer Ambulance Worker Accident Report (VAW-3): Volunteer use this form to report an injury to your Ambulance Squad
  • Volunteer Ambulance Worker Accident Report (VAW-3) (PDF)
• Volunteer Firefighter Accident Report (VF-3): Volunteer use this form to report an injury to your Fire Department
  • Volunteer Firefighter Accident Report (VF-3) (PDF)
• Limited Release of Health Information (C-3.3): Employees complete this form and turn in with the accident report form
  • Limited Release of Health Information (C-3.3) (PDF)
• Medical Authorization: Employees complete this form and turn in with the accident report form
  • Medical Authorization (PDF)
• Physician / Chiropractor Report: Employees take this form with you to your medical provider.
  • Physician / Chiropractor Report (PDF)
• Political Subdivision Report of Injury to VAW (VAW-2) - Volunteer Ambulance Squad Captains use this form to report volunteer injuries to the Self-Insurance Department.
  • Political Subdivision Report of Injury to VAW (VAW-2) (PDF)
• Political Subdivision Report of Injury to VF (VF-2) - Volunteer Fire Department Chiefs use this form to report volunteer injuries to the Self-Insurance Department.
  • Political Subdivision Report of Injury to VF (VF-2) (PDF)