Blank Certificate Of Workers Compensation Insurance Form

The contractor s certificate of workers compensation insurance form 61a is a form issued by commissioners of revenue all over the commonwealth in conjunction with contractor s business license filings.

Blank certificate of workers compensation insurance form. Filed with the government agency issuing a permit license or contract. Workers compensation and employers liability. Acord 25 2001 08 if the certificate holder is an additional insured the policy ies must be endorsed. Pursuant to 58 1 3714 the governing body of each county city or town must require every contractor to provide written certification at the time of any application for issuance or reissuance of a business license.

The form is required to be completed fully and with care. No other form of insurance substitutes. On other pages you ll find we provided you with some real world information as to the effect certificates have on any workers compensation policy. Provide the complete name of the insurance company or other insuring entity providing workers compensation insurance coverage for the business.

For assistance in creating an online account please contact nysif s contact center at 888 875 5790. The contractor should list their name address business and insurance information. The forms are also available in individual listings. Forms available for electronic filing are indicated by see electronic filing online forms for more information about filing your pdf form online.

You ll learn what a certificate is what a certificate of insurance can and cannot do what information is provided on a certificate who needs a certificate of insurance and how to secure one. The nys state insurance fund uses the u 26 3 form as its certificate of nys workers comp insurance. For workers compensation insurance questions please contact the virginia workers compensation commission at 804 205 3586. Enter only workers compensation insurance.

When listing workers compensation insurance it is important to list only active workers compensation insurance. Ny state insurance fund certificate of workers compensation coverage this is the state insurance fund s equivalent of workers compensation board form c 105 2 employers insured for workers compensation through the state insurance fund. Certificate of workers compensation insurance form 61a online. This is a complete listing of all division of workers compensation forms.

The certificate of insurance on the reverse side of this form does not constitute a contract between the issuing insurer s authorized. Please ensure that the form is signed the name of the person signing the form is printed on it and the form is properly dated.