Rejection Of Coverage printable pdf download

Commonwealth of Virginia

Workers’ Compensation Commission

1000 DMV Drive Richmond, VA 23220

vwcinsurance@workcomp.virginia.gov

(804) 205-3586

FAX: (804) 367-2239

OFFICER/MANAGER REJECTION OF COVERAGE

Dear Customer:

Fill out this form when an officer of a corporation or a manager of a LLC elects to reject workers’ compensation coverage for injury by

accident under the Virginia Workers’ Compensation Act. Notice needs to be provided to the employer and a copy must be

filed with the Virginia Workers’ Compensation Commission, 1000 DMV Drive, Richmond, VA 23220. A Rejection of

Coverage is continuous unless a Termination of Prior Officer Rejection of Coverage (form 17A) is filed.

In order for the Rejection of Coverage form to be processed please keep in mind the following guidelines when

completing the form.

Please make sure that the most recent version of our Rejection of Coverage form is being submitted. Copies of the most

updated forms are available on our website at

in the “Employer Forms” section under the

“Employers” tab. You may also request copies by writing to the Commission. Outdated forms will not be accepted.

An Executive Officer is defined in the Act as an employee. An Executive Officer means (i) the president, vice-president,

secretary, treasurer or other officer, elected or appointed in accordance with the charter and bylaws of a corporation and (ii)

the manager elected or appointed in accordance with the articles of organization or operation agreement of a limited liability

company.

A shareholder of a stock corporation having only one shareholder and a member of a limited liability company having only one

member, need not file a rejection of coverage form as they are not considered employees unless they elected to be

covered. See § 65.2-101 n.

The name of the corporation or LLC should be the same as the Charter by which the corporation or LLC is licensed. The name

should also be written on the form as it is registered with the State Corporation Commission. Use the mailing address used by

the corporation or LLC to receive mail by the US Postal Service.

Identify the entity by checking corporation or LLC. Provide the employer’s Federal Identification Number (FEIN) and the State

Corporation Commission Identification Number, if applicable.

Current Workers’ compensation insurance coverage information is to be completed in its entirety. Do not use such terms as

“To Be Assigned”, “Pending” or “Unknown”. Insurance coverage must be active for approval, therefore please do not submit a

form using expired coverage, cancelled coverage or coverage that has not yet been filed. You may use the Insurance

Coverage search tool on our website under the VWC Resources tab to verify coverage prior to submitting.

All requested information must be provided for the officer or manager rejecting coverage. If any information or supporting

documentation is missing then the form will not be processed.

Officer status will be verified by the Commission with the State Corporation Commission. If you anticipate that SCC

information is not current or the corporation is based out of state and not listed in SCC you may submit documentation of

current officer status (e.g. minutes).

Signatures and date of receipt by the employer and officer/manager are required. The form must be signed and dated in both

blanks even if the officer/manager and employer are the same person.

10. The effective date of the rejection of coverage is the last to occur: (i) the policy inception or (ii) the delivery of the notice to

the employer, in accordance with the statute, section 65.2-101.

Please direct any questions or concerns to the Insurance Department of the Virginia Workers’ Compensation Commission by email at

vwcinsurance@workcomp.virginia.gov

or contact by phone weekdays from 8:30 a.m.-4:45 p.m. at (804) 205-3586.

Rev. 10/14

Rejection Of Coverage

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