Fauquier County Department of Fire Rescue           & Emergency Management                                    

62 Culpeper Street                                                                                                                       Warrenton, Virginia 20186                                                                                                                    
Administration / Operations- 540-422- 8800
Training - 540-422-8820

 

 

VFRA Forms


FORM

USE

ACORD Automobile Loss Notice

Vehicle damage

 

ACORD Property Loss Notice

Building damage, portable equipment loss, stolen equipment

ACORD General Liability Loss Notice

Injuries to non-members occurring on company property


Injury Report

Doctor's Form

Fauquier County - Worker's Compensation Panel of Physicians



Effective July 1, 2017

Reporting of injuries, illnesses, exposures related to Fire/Rescue work (Until Company Nurse is officially set up, you must complete both forms to the left. These forms will need to be completed in the event of a volunteer injury.)

email these two forms to:

riskmanagement@fauquiercounty.gov

Directions:

  • **Insurance forms must be submitted to the Fauquier County Department of Fire, Rescue and Emergency Management (DFREM) office within 24 hours of the incident.
  • **Reports can be emailed to VFRAClaims@fauquiercounty.gov or faxed at 540-422-8813 to: Attention Claims Administrator.  Forms are available on the www.fauquierfirerescue.org website under ADMINISTRATIVE FORMS. 
  • All possible exposures to communicable diseases must be reported to the EMS committee chairperson or the DFREM Chief within 24 hours of the incident. Either individual, or their designee, can be reached by cell phone or through the communications center.
  • Any member with a workers’ compensation claim must be evaluated by a physician found on the “Fauquier County Fire & Rescue Association Workers’ Compensation Panel of Physicians”. (Copy attached to form)
  • Volunteer Injuries Effective July 1, 2017

    Reporting of injuries, illnesses, exposures related to Fire/Rescue work (Until Company Nurse is officially set up, you must complete both forms to the left. These forms will need to be completed in the event of a volunteer injury.)

    email these two forms to:

    riskmanagement@fauquiercounty.gov

**It is the company’s responsibility to assure that all insurance forms completed arrive at the DFREM office.  Call 540-422-8800 or 540-422-8804 to verify that the Email or FAX was received.

    New Members: Please complete the forms that are * below. 

      New Member Application Tutorial
    (Please follow these steps)

         *  Application Package Approval Checklist

         *  Volunteer Application 11-2011Rev

         *  Fauquier - LifeInsurancePacket  

    Transfer Membership: Please complete the forms that are ** below.

       Vol. Members Move/Change Agency Tutorial
    (Please follow this steps)

         **  Fauquier Volunteer Action Form

         **  Volunteer Permission to Release Information

     

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