Rejection Of Coverage Page 2
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1
2Officer/Manager
PLEASE COMPLETE FULLY AND LEGIBLY
Rejection of Coverage
OR FORM CANNOT BE PROCESSED
Virginia Workers’ Compensation Commission
1000 DMV Drive Richmond Virginia 23220
(804) 205-3586
FAX: (804) 367-2239
vwcinsurance@workcomp.virginia.gov
All Information Requested is Required
Employer Information
Officer/Manager Information
Corporation/LLC Name: _____________________________________
Last Name: ___________________________________________
Address: _________________________________________________
First Name: _________________________________ MI:______
Suite/Bldg: _______________________________________________
Address:______________________________________________
City: ___________________________ State: _______ Zip: ________
_____________________________________________
Corporation:
LLC:
City:_________________________ State: ______ Zip: _______
Business FEIN:
SSN (last four digits required):___________________________
(Federal ID Number):_______________________________________
Officer Title (for those eligible to reject):
Va State Corporation
Officer status will be verified with the State Corporation
Commission ID No: ________________________________________
Commission.
For a Corporation (check one)
President
Vice President
Secretary
Treasurer
Other(*) __________________________________________
*For “Other” titles, corporate charter and bylaws showing title must
Employer’s Insurance Information
be included with filing
For a LLC
Ensure coverage is filed prior to submitting form to Commission
Manager of a Multiple Member LLC
LLC Managers or Managing Members must include the employer’s
Insurance Carrier or
Operating Agreement or Articles of Organization showing Manager
Self Insured Group:
__________________________________
election or appointment in order to verify Manager status.
Policy Number:
__________________________________
Are you paid salary or wages on a regular basis at an
agreed amount?
Policy Period:
__________________________________
Yes
No
(Response Required)
Pursuant to the provision of Section 65.2-300 of the Virginia Workers’ Compensation Act, the undersigned hereby rejects the
right to claim workers’ compensation benefits for injuries by accident. This rejection of coverage shall be effective as of the
last to occur (i) the policy inception or; (ii) the delivery of the notice to the employer, pursuant to §65.2-300
Signature of Officer/Manager
Date signed:
Signature of Employer
Date notice received by Employer:
Complete section below for Agent or Agency to receive a copy of the 16A Approval
Agency Name: _____________________________________
Agent Name: ____________________________________________
Address:___________________________________________
Agent Telephone: ________________________________________
City: ____________________State: _________Zip:________
Agent Email: _____________________________________________
Rev. 10/14
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