Form 17a - Officer/manager Revocation Of Prior Rejection Of Coverage Page 2

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INSTRUCTIONS
OFFICER/MANAGER
REVOCATION OF PRIOR
REJECTION OF COVERAGE (FORM 17A)
FILE A SINGLE COPY OF THIS FORM WITH THE VIRGINIA WORKERS’ COMPENSATION COMMISSION.
READ THESE INSTRUCTIONS CAREFULLY PRIOR TO COMPLETING THIS FORM.
1. Fill out this form whenever an officer of a corporation or the managers of an LLC elects to terminate a prior
rejection of coverage for an injury or accident under the Virginia Workers’ Compensation Act.
2. The name of the corporation/LLC should be the same as the Charter by which the corporation or LLC is licensed,
and the same name used on the Form 16A when coverage was rejected. Use the mailing address used by the
corporation or LLC to receive mail by the U.S. Postal Service.
3. Identify the entity by checking corporation or LLC. Provide the employer’s Federal Identification Number and the
State Corporation Commission Identification Number, if applicable.
4. Provide all requested information for the officer/manager rejecting coverage.
5. Signatures of the employer, officer/manager and the witness are required.
You may print copies of this form by accessing our website
or request copies by
writing to the Commission.

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