Form 16a - Officer/manager Rejection Of Coverage
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1
2Officer/Manager
PLEASE COMPLETE FULLY AND LEGIBLY
Rejection of Coverage
OR FORM CANNOT BE PROCESSED
FILING INSTRUCTIONS ON REVERSE SIDE
Virginia Workers’ Compensation Commission
1000 DMV Drive Richmond Virginia 23220
1-877-664-2566
All Information Requested is Required
Last Name:
Corporation /LLC Name:
First
Address:
Name:
MI:
Address:
Suite/Bldg:
City:
State:
Zip:
Corporation:
LLC:
City:
State:
Zip:
Business FEIN:
(Federal ID Number)
SSN: ________________________________________________
Last Four Digits Required
VA State Corporation
Identification
Officer Title:
President
Secretary
Number:
(Check One)
Vice President
Treasurer
Insurance
Manager LLC
Other
(*)
Insurance Carrier or
Are you paid salary or wages on a regular basis at an agreed
Self Insured Group:
amount?
Policy Number:
Yes
No
Policy Period:
(Response Required)
Pursuant To the provisions 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.
Signature of Officer/Manager
Date
Signature of Employer (By)
Date
Signature of Witness
Date
Insurance Agent Information (Optional)
Agency Name:
Agent Name:
Address:
Agent Telephone:
Agent E-mail:
City:
State:
Zip:
Form #16A
Rev. 02/11
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