Form 17a - Officer/manager Revocation Of Prior Rejection Of Coverage
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1
2Officer/Manager
PLEASE COMPLETE FULLY AND LEGIBLY
Revocation of Prior
OR FORM CANNOT BE PROCESSED
Rejection of Coverage
FILING INSTRUCTIONS ON REVERSE SIDE
Virginia Workers’ Compensation Commission
1000 DMV Drive Richmond Virginia 23220
All Information Requested is Required
1-877-664-2566
Last Name:
Corporation /LLC Name:
First
Name:
Address:
MI:
Address:
Suite/Bldg:
City:
State:
Zip:
Corporation:
LLC:
City:
State:
Zip:
Business FEIN:
SSN: ________________________________________________
(Federal ID Number)
Last Four Digits Required
VA State Corporation
Identification Number:
This is notice that the undersigned hereby revokes a prior rejection of workers’ compensation coverage and now accepts
coverage under the Act, as provided in Section 65.2-300, and hereby accepts the provisions of the Workers’ Compensation Act.
Signature of Officer/Manager
Date
Signature of Employer (By)
Date
Signature of Witness
Date
Insurance Agent Information (Optional)
Agency Name:
Agency Name:
Address:
Agent Telephone:
Agent E-mail:
City:
State:
Zip:
A copy of this notice must be handed to the employer or sent by registered mail. An additional copy must be filed with the
Virginia Workers’ Compensation Commission, 1000 DMV Drive, Richmond, VA 23220.
Form #17A
Rev. 02/11
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