Notice Of Cancellation Or Non Renewal {45H}

VIRGINIA WORKERS COMPENSATION COMMISSION 1000 DMV DRIVE, RICHMOND, VA 23220 INSURANCE DEPARTMENT WWW.VWC.STATE.VA.US NOTICE OF CANCELLATI ON OR NON-RENEWAL (VWC FORM NO. 45H) Use this form to report any cancellation or non-renewal of workers compensation insurance in Virginia. Also use the form to report any reinstatement of a cancelled policy, anyrew ritten policy, or any renewal of a non-renewed policy. Send the original to: File electronically or send single copy to: VA Workers Compensation Commission NCCI Insurance Department C/O First Image Data Input Division 1000 DMV Drive P.O. Box 7369 Richmond, VA 23220 London, KY 40742-7369 Insured name and address Carrier Name and address IISS TTHHIISS AA MMAASSTTEERR PPOOLLIICCYY IISSSSUUEEDD TTOO AA Carrier NCCI Code Number__________________ PPRROOFF EESSSSIIOONNAALL EEMMPPLLOOYYEERR OORRGGAANNIIZZAATTIIOONN PPRROOVVIIDDIINNGG CCOOVVEERRAAGGEE TTOO IITTSS CCLLIIEENNTTSS?? Policy Period______________to________________ (Response required) YES NO Non-pay Insured S/S # or FEIN_____________________ Type of Cancellation: Other Policy number____________________________ Cancelled by carrier Check here if a copy of the Notice is being sent to the insured. Requested date _____/_____/_____ Cancelled by insured (includes request by finance company) Requested date _____/_____/_____ Non-renewed Requested date _____/_____/_____ ======================================================================== ========= Use this section to report reinstatement, renewal or rewritten coverage information. VWC Reference Number:__________________ Reinstated without a lapse in coverage. Reinstated with a lapse in coverage. Effective Date of Reinstatement ______/_______/_________ Policy Renewed New Policy Number_______________________ Policy Rewritten New Policy Number________________________ ======================================================================== ==========- Submitted by:____________________________________ Date:______________________________________ Must be si(gned by authorized carrier representative) VWC Form 45H (rev.7/04) American LegalNet, Inc. www.USCourtForms.com