Form 61-A - Contractor'S Certification Of Workers' Compensation Liability Page 2
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2INSTRUCTIONS FOR COMPLETION OF VWC FORM 61-A
Contractor’s Certification of Workers’ Compensation Liability
To be completed by the official issuing the business license.
1. Check one. City, Town or County.
Provide the name of locality issuing the license.
.
Provide business license number including any prefix or suffix
To be completed by the contractor. All information requested is required.
2.
Applicant’s name, mailing address and phone number are required.
3.
Provide complete name of business. Sole-proprietors and partners should include the trade name under
which the business operates.
4.
Provide the complete business address used to receive mail by the U.S. Postal Service.
5.
Provide the Federal Employer Identification Number (FEIN). If one has not been issued, list the
Temporary FEIN issued by the Virginia Tax Dept. If a sole proprietor with neither, list your social security
number.
6.
Check the legal status of the business.
7.
Provide the type of trade/industry in which the business is classified.
8.
Provide the business phone number and e-mail if available.
9.
Provide the complete name of the insurance company or other insuring entity providing workers’
compensation liability insurance for the business. If insured with a carrier, provide carrier name and
policy number. If self–insured, provide name on certificate and certificate number. If group self-insured,
provide group name and member number. If insured under a Professional Employer Organization (PEO)
master policy, provide PEO name and policy number. For all coverage provide policy effective dates.
Do not use the name of an insurance agency.
If the name of the insurance company is unknown, contact the agent for this information.
10.
For contractors that indicate workers’ compensation is not required, indicate if you hire subcontractors to
assist you in your work or in fulfilling your contracts.
11.
For general information regarding whether workers’ compensation coverage is required, please review the
brochure provided or contact the Virginia Workers’ Compensation Commission at 1-877-664-2566.
12.
Sign the form and print the name of the person signing the form.
13.
Date the form and present it to the licensing authority.
Note: The state funds of West Virginia and Maryland are not authorized to write workers’ compensation
insurance in Virginia.
DO NOT ATTACH ANY DOCUMENTS TO THE CONTRACTOR’S CERTIFICATE.
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