Virginia > Workers Compensation
Officer Manager Revocation Of Prior Rejection Of Coverage 17A - Virginia
| Officer Manager Revocation Of Prior Rejection Of Coverage Form. This is a Virginia form and can be used in Workers Compensation . |
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Officer/Manager Revocation of Prior Rejection of Coverage www.workcomp.virginia.gov Virginia Workers' Compensation Commission 1000 DMV Drive Richmond Virginia 23220 1-877-664-2566 PLEASE COMPLETE FULLY AND LEGIBLY OR FORM CANNOT BE PROCESSED FILING INSTRUCTIONS ON REVERSE SIDE All Information Requested is Required Corporation /LLC Name: Address: Last Name: First Name: MI: Suite/Bldg: Address: City: State: Zip: Corporation: LLC: City: State: Zip: Business FEIN: (Federal ID Number) SSN: ________________________________________________ Last Four Digits Required VA State Corporation Identification Number: This is notice that the undersigned hereby revokes a prior rejection of workers' compensation coverage and now accepts coverage under the Act, as provided in Section 65.2-300, and hereby accepts the provisions of the Workers' Compensation Act. Signature of Officer/Manager Date Signature of Employer (By) Date Signature of Witness Date Insurance Agent Information (Optional) Agency Name: Agency Name: Address: Agent Telephone: Agent E-mail: City: State: Zip: 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. 4 Form #17A Rev. 02/11 American LegalNet, Inc. www.FormsWorkFlow.com L L INSTRUCTIONS OFFICER/MANAGER REVOCATION OF PRIOR REJECTION OF COVERAGE (FORM 17A) FILE A SINGLE COPY OF THIS FORM WITH THE VIRGINIA WORKERS' COMPENSATION COMMISSION. READ THESE INSTRUCTIONS CAREFULLY PRIOR TO COMPLETING THIS FORM. 1. Fill out this form whenever an officer of a corporation or the managers of an LLC elects to terminate a prior rejection of coverage for an injury or accident under the Virginia Workers' Compensation Act. 2. The name of the corporation/LLC should be the same as the Charter by which the corporation or LLC is licensed, and the same name used on the Form 16A when coverage was rejected. Use the mailing address used by the corporation or LLC to receive mail by the U.S. Postal Service. 3. Identify the entity by checking corporation or LLC. Provide the employer's Federal Identification Number and the State Corporation Commission Identification Number, if applicable. 4. Provide all requested information for the officer/manager rejecting coverage. 5. Signatures of the employer, officer/manager and the witness are required. You may print copies of this form by accessing our website www.workcomp.virginia.gov or request copies by writing to the Commission. American LegalNet, Inc. www.FormsWorkFlow.com
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