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Vwc Form 61a - Contractor'S Certification Of Insuring Liability For Workers' Compensation In Virginia 1999

Contractor's Certification of Insuring Liability for Workers’ Compensation In Virginia

Complete and file this form with each Virginia locality where you have applied for or are renewing a business license

Name of City, Town or County in Virginia Is suing License: ____________________________

(A separate certificate must be filed with each locality in which you obtain a license.)

Business License Number Issued by the locality named above: __________________________

Name of Contractor:__________________________________________________

Contractor’s Address:_________________________________________________

________________________________________________

Contractor’s FEIN

SSN:____________________________________________

Contractor’s Telephone Number: (____) ________________________________

Legal Status: __

Sole Proprietor ___ Partnership ___ Corporation ___ LLC ___ Other (specify)

(Check One)

__________________________

Method by which contractor’s liability for workers’ compensation is insured:

___ Insured by an insurance carrier licensed to do business in Virginia: (Maryland and West Virginia Employers

please see note below.)

Name of Carrier:________________________________________

Policy Number:___________________________ Policy Effective Date:___________________________________

___ A member of a group self-insured association licensed to do business in Virginia:

Name of Self-Insured Group: _____________________________________________________________________

Member Number: _______________________

Effective Date:________________________________________

___ Self-Insured by the Virginia Workers’ Compensation Commission. Member Number: _______________________

___ Workers’ Compensation Insurance is not required. State Reason: ________________________________________

Under penalty of law, the undersigned certifies he/she is duly authorized by the business license applicant to execute

this certificate, and the business named above is in compliance with ' ' 65.2-800 et seq. 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 or Authorized Agent: ___________________________________________

Print Name of Applicant or Authorized Agent: _______________________________

Date: __________________

VWC Form No. 61A (rev. 1/99)

Vwc Form 61a - Contractor'S Certification Of Insuring Liability For Workers' Compensation In Virginia 1999