Notice Of Change Cancellation Or Non-Renewal {45H-GSIA}

COMMONWEALTH of VIRGINIA Notice of Change, Cancellation or Non-Renewal (VWC Form No. 45H-GSIA ­ 7/16/04) Use this form to report any new members, any changes in member names or addresses, and any cancellation or non-renewal of members. Also use the form to report any reinstatement of a cancelled member or any renewal of a previously non-renewed member. Cancellations shall be effective 30 days after receipt of this notice by the Virginia Workers' Compensation Commission, except that cancellations for non-payment shall be effective 10 days after receipt. All non-renewals shall be effective 30 days after receipt by the Virginia Workers' Compensation Commission. Cancellations at the request of the member shall be effective the date the notice is received by the Virginia Workers' Compensation Commission. One copy each to: Insurance Department VA Workers' Compensation Commission 1000 DMV Drive Richmond, VA 23220 Bureau Of Insurance State Corporation Commission Post Office Box 1157 Richmond, VA 23209 Appropriate membership forms should be attached to the SCC copy only. Member name and address: VWC Group Association Number: 009 ___ ___ Member Number: Effective From: FEIN: List any subsidiaries or "T/A" names below. Include the address if it is different from that of the main member. ACTION: New member/subsidiary Change in member/subsidiary name Change in member/subsidiary address Cancelled by group Cancelled by member Requested date of cancellation: Reinstated by group effective: Non-renewed by group Non-renewed by member Renewed by group effective: Comments: Submitted by: Name: Date: American LegalNet, Inc. www.USCourtForms.com Type: Non-pay Other