Form 16a - Rejection Of Coverage Under The Virginia Workers' Compensation Act

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Virginia Workers' Compensation Commission
1000 DMV Drive
Richmond, Va 23220
REJECTION OF COVERAGE UNDER
THE VIRGINIA WORKERS' COMPENSATION ACT
EMPLOYER INFORMATION
q q
______________________________
Corporation
Corporate/L.L.C. Name
OR
q q
.
______________________________
L.L.C
(Check One)
Street Address
______________________________
Federal Identification Number
______________________________
______________________________
City
State Zip Code
Va. State Corporation Number
===========================================
OFFICER/MANAGER REJECTING COVERAGE
______________________________
______________________________
Name (Last, First and Middle Initial)
Social Security Number
______________________________
______________________________
Street Address
Date of Hire (Month/Day/Year)
______________________________
Are you paid a salary or wages on a regular basis at an
q q
q q
City
State
Zip Code
agreed upon amount?
Yes
No (Corporate
Officers Only)
______________________________
Title of Officer (Manager, if applicable)
===========================================
Current Coverage Information
__________________________
________________
________
to __________
Name of Insurance Carrier or
Policy Number
Policy Period
Self-Insured Group
===========================================
Pursuant to the provisions of §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/Member
Date
_____________________________
_________________
Signature of Employer
(By)
Date
_____________________________
_________________
Witness
Date
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.
VWC Form No. 16A (rev, 1/1/99)
(See opposite side for instructions to complete this form.)

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