Certificate Of Workers' Compensation Insurance Form (Page 2 of 2) in pdf

INSTRUCTIONS FOR COMPLETING THE VWC FORM 61-A

To be completed by the official issuing the business license.

Check one. City, Town or County.

Provide the name of locality issuing the license.

Provide business license number including any prefix or suffix.

To be completed by the contractor. All information requested is required.

Enter the Business owner / Contractor’s name, mailing address and phone number, all information is required.

Enter the complete name of business. Additionally list the trade name under which the business operates if a trade name is used.

Enter the business address that is used to receive mail by the U.S. Postal Service, if this address is different from the business

owner / contractor’s address.

Provide the Federal Employer Identification Number (FEIN) for the business. If one has not been issued, list the Temporary FEIN

issued by the Virginia Tax Dept. If you are a sole proprietor with neither, list your social security number; however it is best to

obtain a FEIN, given the restrictions on the use of social security numbers.

Check the legal status of the business.

Provide the type of trade or industry in which the business is classified.

Enter the business phone number if there is one and the business e-mail if there is one.

only

Provide the workers’ compensation insurance information if you have coverage. Enter

workers’ compensation insurance.

No other form of insurance substitutes. Provide the complete name of the insurance company or other insuring entity providing

workers’ compensation insurance coverage for the business. Also enter the policy or member number and policy effective dates.

Do not list the name of an insurance agent or agency. If you do not know or recall the name of your insurance company or

insuring entity, please contact your agent to obtain this information.

10.

Out of state employers, please note, Virginia requires valid Virignia workers’ compensation coverage for work performed in

Virginia. For a business that has a valid policy based outside Virginia, if the business either performs or subcontracts work in

Virginia, the business needs valid Virginia coverage and may usually secure valid Virginia coverage with the proper Virginia

Amendatory Endorsement, adding Virginia to Item 3A of the policy. An employer from a monopolistic state must usually obtain

separate coverage from a Virginia licensed insurance carrier.

11.

If you do not have / list workers’ compensation insurance on your form you must answer additional questions,

please answer whether you have more than two employees and whether you hire subcontractors to assist in your work. A

response to these questions is required.

12.

Virginia workers’ compensation insurance coverage requirements.

Virginia law requires that every employer who

regularly employs more than two part-time or full-time employees purchase and maintain workers' compensation insurance. A

business that hires subcontractors to assist in the work of the business or fulfill a contract of the business must count the

subcontractor’s employees when counting employees to determine if / when coverage is required. This is true even if the

subcontractor has their own workers’ compensation coverage.

A contractor should gather proof of coverage from all

subcontractors hired and should not be charged insurance premium for subcontractors that have their own coverage.

Regardless, a contractor that hires subcontractors with employees must count the subcontractor’s employees when counting total

employees and determining when and whether the contractor is required to carry coverage.

13.

Please ensure that the form is signed, the name of the person signing the form is printed on it and the form is properly dated.

14.

For workers’ compensation insurance questions please contact the Virginia Workers’ Compensation Commission at 804 205-3586.

15.

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

Note: The state funds of West Virginia and Maryland are not authorized to write workers’ compensation insurance in Virginia.

DO NOT ATTACH ANY DOCUMENTS TO THE CONTRACTOR’S CERTIFICATE.

Certificate Of Workers' Compensation Insurance Form Page 2

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