Certificate Of Workers' Compensation Insurance Form printable pdf download

Contractor’s

Certificate of Workers’

Compensation Insurance

(Form 61-A)

PLEASE COMPLETE FULLY AND LEGIBLY

INSTRUCTIONS ON REVERSE SIDE

File this completed form at the local office

where your business license is obtained

Locality Issuing License:

Name of Locality:

Business or Trade Name

Business License Number:

City

Town

County

Name of Business Owner/ Contractor

Business Federal Employer ID (FEIN) or Tax ID Number:

Last:

First:

Business Owner / Contractor’s Home Mailing Address:

Business Address if different from Business Owner Address:

City:

State:

Zip:

City:

State:

Zip:

Home Telephone:

Business: Corp.

L.L.C.

Sole Prop

Partnership

Other

WORKERS’ COMPENSATION INSURANCE

Type of Trade or Industry:

If you have workers’ compensation insurance check type and complete below:

Business Telephone:

E-mail Address:

List ONLY WORKERS’ COMPENSATION, not General Liability

If you do not list workers’ compensation

Insurance Carrier licensed in Virginia

insurance you must answer below:

1. Do you have more than two part-time or full-time employees?

Self-insured with certificate of authorization issued by the

Virginia Workers’ Compensation Commission

(Note: Corporate officers, LLC managers, part-time employees and

employees of your subcontractors generally count as your employees for

Workers’ compensation purposes. Filing of a 1099, payment of cash wages

Group Self-Insurance Association (GSIA) licensed by the State

or designating a worker an “Independent Contractor” does not necessarily

Corporation Commission

Eliminate or alter employee status under the Workers’ Compensation Act.)

Yes

A Professional Employer Organization (PEO) registered in Virginia

Name of Insurance Carrier, Self-Insured, GSIA or PEO:

2. Do you hire Independent Contractors or subcontractors with

employees to assist you in your work?

Policy, Master Policy or Certificate Number:

Yes

Policy Effective Date and Policy Period:

Failure to insure when required by law shall subject an employer to

civil penalties of up to $250 per day uninsured, subject to a maximum

penalty of $50,000.00 plus costs, pursuant to Virginia Code § 65.2-805

Under penalty of perjury, the undersigned certifies s/he is duly authorized by the business license applicant to execute this certificate;

the information provided herein is correct; and the business is in compliance with Chapter 8 of Title 65.2 of the Virginia Workers’

Compensation Act and will remain in compliance with the law during the effective period of the business license.

Signature of Applicant (Contractor or Business Owner)

Date

Print Name of Applicant

Form 61-A is prepared and distributed by the Virginia Workers’ Compensation Commission to local licensing authorities for use in compliance with §58.1-3714,

Code of Virginia. Form 61 A is available online at

Return this form to the licensing authority, not to the Virginia WC Commission.

For questions regarding how to complete this form, please contact the Commission toll-free at 1-877-664-2566 or 804 205-3586

Certificates of Insurance Cannot be accepted in Lieu of a Completed Form

Return your completed form to the licensing authority where your business license is obtained

61A

rev 070114

Certificate Of Workers' Compensation Insurance Form

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