Form 61-A - Contractor'S Certification Of Workers' Compensation Liability

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Contractor’s
Certification of Workers’
Compensation Liability
(Form 61-A)
PLEASE COMPLETE FULLY AND LEGIBLY
This form must be filed in each Virginia locality where
FILING INSTRUCTIONS ON REVERSE SIDE
a contractor applies for or renews a business license
Locality Issuing License:
Name of Locality:
Business or Trade Name:
Business License Number:
City
Town
County
Name of Applicant
Business FEIN or Tax ID Number:
Last:
First:
Applicant Mailing Address:
Business Address:
City:
State:
Zip:
City:
State:
Zip:
Home Telephone:
Business: Corp.
L.L.C.
Sole Prop
Partnership
Other
METHOD of INSURING FOR WORKERS’ COMPENSATION LIABILITY:
Type of Trade or Industry:
Indicate One:
Business Telephone:
E-mail Address:
Insurance Carrier licensed in Virginia
Self insured with certificate of authorization issued by the Virginia
Not
Check Here if Workers’ Compensation is
Required
Workers’ Compensation Commission
Reason:
Group Self-Insurance Association (GSIA) licensed by the State
Less than 3 employees
Corporation Commission
(Note: Corporate officers, LLC managers, part-time employees and
employees of your subcontractors generally count as your employees for
A Professional Employer Organization (PEO) registered in Virginia
workers’ compensation purposes. Filing of a 1099, payment of cash wages
or designating a worker an “Independent Contractor” does not necessarily
alter employee status under the Workers’ Compensation Act.)
Name of Insurance Carrier, Self-Insured, GSIA or PEO:
Other
(Explain)
Policy, Master Policy or Certificate Number:
If you answered workers’ compensation Not Required, answer below:
Do you hire Independent Contractors or subcontractors to assist you
in your work?
Policy Effective Date and Policy Period:
Yes
No
For VWC Use Only:
Under penalty of law, the undersigned certifies s/he is duly authorized by the business license applicant to execute this certificate; the
information provided herein is correct; and the business is in compliance with Chapter 8 of Title 65.2 of the Virginia Workers’
Compensation Act and will remain in compliance with the law during the effective period of the business license.
Signature of Applicant
Date
Print Name of Applicant
Form 61-A is prepared and distributed by the Virginia Workers’ Compensation Commission to local licensing authorities for use in compliance
with Section 58.1-3714, Code of Virginia. Form 61 A is also available online at
If there are any questions regarding this form, please contact the Commission toll-free at 1-877-664-2566
Form #61-A
Rev. 11/10

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