Contractor Certificate Of Insurance Form Pdf

This certificate of insurance does not constitute a contract between the issuing insurer s authorized representative or producer and the certificate holder.

Contractor certificate of insurance form pdf. The certificate holder information on the certificate of liability insurance coi document must read the same as our mailing address. For questions regarding how to complete this form please contact the commission toll free at. Www workcomp virginia gov return this form to the licensing authority not to the virginia wc commission. Insurance certificates will only be accepted from the contractor and not from the insurance carriers.

Format for submitting proof of insurance for contractor s license most important unless submitting the certificate of insurance with the license application or renewal please include a cover letter or use the notice of insurance form see page 6 to ensure it is matched to. A certificate of liability insurance form is a summary of the benefits available in a company s insurance policy. Certificate of contract completion and contractor s affidavit contractor. That the work under the above named contract including all amendments thereto has been satisfactorily completed.

Palm beach county c o contractors certification 2300 n. Contractors with questions may contact the insurance department of the commission by calling 804 205 3586 or via e mail at vwcinsurance workcomp virginia gov. The insured party s details and the insurance company s background are indicated in the document. That all charges or bills for labor or services.

Contractors that would like further information concerning virginia workers compensation insurance requirements should review the contractor s information sheet. Certificate does not affirmatively or negatively amend extend or alter the coverage afforded by the policies below. This form is a single paged document that consist of the details that the third party needs to know. For information regarding worker s compensation coverage refer to the license application and or the application instructions.

Per accident ea accident n a subr wvd addl insr. Or 804 205 3586. Form must be completed by the insurance agent or insurance company not by the business contractor. Contractor s certificate of workers compensation insurance form 61 a electronic filing available online www workcomp virginia gov please complete fully and legibly return to.

Thea project no. Certificates of insurance cannot be accepted in lieu of a completed for m. The terms of the insurance policy control over the terms of the certificate of insurance. Insurance department 333 e.

Franklin street richmond va 23219 name of business owner contractor last. This is to certify that the insurance policy listed below has been issued to the named insured for the policy period indicated and that the policy meets the minimum coverage requirements applicable under minnesota statutes section 326b 86 subd. Virginia workers compensation commission attention.