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Officer Manager Rejection Of Coverage 16A - Virginia

Officer Manager Rejection Of Coverage Form. This is a Virginia form and can be used in Workers Compensation .
 Fillable pdf Last Modified 2/4/2014
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Officer/Manager Rejection of Coverage Virginia Workers' Compensation Commission 1000 DMV Drive Richmond Virginia 23220 1-877-664-2566 www.workcomp.virginia.gov PLEASE COMPLETE FULLY AND LEGIBLY OR FORM CANNOT BE PROCESSED FILING INSTRUCTIONS ON REVERSE SIDE All Information Requested is Required Corporation /LLC Name: Address: Suite/Bldg: City: Corporation: Business FEIN: State: LLC: Zip: Last Name: First Name: Address: MI: City: State: Zip: (Federal ID Number): SSN: ________________________________________________ Last Four Digits Required VA State Corporation Identification No: Officer Title: (Check One) President Secretary Treasurer Manager LLC (*) Vice Pres Other(**) Insurance Carrier or Self Insured Group: Policy Number: Policy Period: Insurance *Operating agreement or articles of org. must be included **Corporate charter and bylaws must be included w/filing A Director or LLC member cannot Reject coverage Officer status will be verified in S.C.C. Are you paid salary or wages on a regular basis at an agreed amount? (Response Required) Yes No Ensure coverage is filed prior to submitting form to Commission. Pursuant To the provisions of Section 65.2-300 of the Virginia Workers' Compensation Act, the undersigned hereby rejects the right to claim workers' compensation benefits for injuries by accident. Signature of Officer/Manager Signature of Employer (By) Signature of Witness Date Date Date Insurance Agent Information (Complete if agent requests copy of approval) Agency Name: Address: Agent Name: Agent Telephone: Agent E-mail: City: State: Zip: Form 16A Rev. 08/01/13 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS OFFICER/MANAGER REJECTION OF COVERAGE (VWC FORM 16A) FILE A SINGLE COPY OF THIS FORM WITH THE VIRGINIA WORKERS' COMPENSATION COMMISSION. READ INSRUCTIONS CAREFULLY PRIOR TO COMPLETING THIS FORM. 1. Fill out this form whenever an officer of a corporation or a manager of an LLC elects to reject workers' compensation coverage for 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. 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. *An Executive Officer means (i) the president, vice-president, secretary, treasurer or other officer, elected or appointed in accordance with the charter and bylaws of a corporation and (ii) the manager elected or appointed in accordance with the articles of organization or operating agreement of a limited liability company. A Director is not an executive officer and is not qualified to reject coverage under the Act. 5. Officer status will be verified by the Commission in State Corporation Commission (SCC). If you anticipate that SCC information is not current you may submit documentation of more current officer status (e.g. minutes). 6. Provide all requested information for the officer/manager rejecting coverage. check "Yes" or "No" to the questions regarding salary or wages. Officers of a corporation must 7. Provide current workers' compensation insurance coverage information. Do not use such terms as "To Be Assigned," "Pending" or "Unknown." Coverage must be active for approval, therefore please do not submit form until coverage is filed. 8. Signatures of the employer, officer/manager and the witness are required. 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. Officer/Manager Rejection of Coverage is continuous unless ended by filing a Termination of Prior Officer Rejection of Coverage (Form 17A). You may print copies of this form by accessing our website www.workcomp.virginia.gov or request copies by writing to the Commission. Form 16A Rev. 08/01/13 American LegalNet, Inc. www.FormsWorkFlow.com
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