Contractor S Certificate Of Workers Compensation Insurance Form

Provide the complete name of the insurance company or other insuring entity providing workers compensation insurance coverage for the business.

Contractor s certificate of workers compensation insurance form. Washington insurance forms and workers comp applications such as owners inclusion or exclusion forms are sometimes updated by the state. Click here to complete the form and receive your acknowledgement of compliance. No other form of insurance substitutes. Form 61 a is available online at www workcomp virginia gov return this form to the licensing authority not to the virginia wc commission.

Certificate of workers compensation insurance form 61a certificate of workers compensation insurance form 61a electronic filing of the contractor certification form 61a is now available. Application for elective coverage sole proprietor partners for profit corporate officers or member managers of limited liability company llc f213 042 000. Annual supplemental surety information f207 125 000. Virginia workers compensation commission attention.

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. Franklin street richmond va 23219 name of business owner contractor last. 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. Frequently asked questions about independent contractor status.

Certificate of workers compensation insurance form 61a online. 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 that. 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. Enter only workers compensation insurance.

You have the right to appeal this decision within 10 days from the date of the board s decision. All appeals must be in writing and mailed to. Acknowledgement of security interest f207 143 000. Form 61 a is prepared and distributed by the virginia workers compensation commission to local licensing authorities for use in compliance with 58 1 3714 code of virginia.

Insurance department 333 e. View more insurance forms and publications. 2430 chandler court sw po box 42401 olympia wa 98504 2401 360 753 6823 board of industrial insurance appeals. Lindsay lizzotte maine workers compensation board 27 state house station augusta me 04333 0027.

Workers compensation provides no fault industrial insurance coverage for most employers and workers in washington. A workers compensation certificate of insurance coi is proof that a business carries workers comp coverage. You may have heard a workers compensation certificate referred to by different names such as coi insurance certificate certificate of insurance form subcontractor certificate of insurance or proof of insurance.