61A rev 11 / 13 /2017 Certificate Compensation Insurance (Form 61 - A) Electronic Filing Available O nl ine www.workcomp.virginia.gov PLEASE COMPLETE FULLY AND LEGIBLY RETURN TO: Attention: Insurance Dep artment 333 E. Franklin Street Richmond , VA 23219 Name of Business Owner /Contractor Last: Business or Trade Na me First: B usiness Federal Employer ID (FEIN) or Tax ID Number: Business Owner Home Mailing Address: Business Address if differ ent from Business Owner Address : City: State: Zip: City: State: Zip: Home Telephone: Business: Cor p. L.L.C. Sole Prop Partnership Other # of o fficers # of paid members # of partners: and complete below: Type of Trade or Industry: List ONLY not General Liability Insurance Carrier licensed in Virg inia Self - insured with certificate of authorization issued by the Group Self - Insurance Association (GSIA) licensed by the State Corporation Commission A P rofessional Employer Organization (PEO) registered in Virginia Business Telephone: E - mail Address: If you do not list workers compensation insurance you must answer below: 1. Do you have more than two part - time or full - time employees ? (N ote: Corporate officers, LLC managers, part - time employees and employees of your subcontractors generally count as your employees for Workers Filing of a 1099, payment of cash wages or designating a worker a e liminate or alter Yes No 2. Do you h ire Independent Co ntractors or subcontractors with employees to assist you in your work? Yes No What is the number of subcontractor workers that assist you in your work? Failure to insure when required by l aw shall subject an employer to civil penalties of up to $ 2 5 0 per day uninsured, subject to a maximum penalty of $50,000.0 0 plus costs, pursuant to Virginia Code 247 65.2 - 805 NCCI Carrier Code Name of Insuran ce Carrier, Self - Insured, GSIA or PEO: Policy, Master Policy or Certificate Number: Policy Effective Date : Policy Expiration Date: Under penalty of perjury , the undersigned certifies s/he is duly authorized by the business license applicant to execute this certificate; the information provided herein is correct; and the business is in compliance with Chapter 8 of Title 65.2 of the Vir Compensation Act and will remain in compliance with the law during the effective period of the bus iness license. Signature of Applicant (Contractor or Business Owner) Date Print Name of Applicant For questions regarding how to complete this form, please contact the Commission toll - free at 1 - 877 - 664 - 2566 or 804 205 - 3586 Certificates of Insuran ce Cannot be A ccepted in Lieu of a Completed Form American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETING THE VWC FORM 61 - A To be completed by the contractor. All information requested is required. 1. Enter the B ailing address and phone number, all information is required. 2. Enter the comp lete n ame of business. Additionally list t he trade name un der which the business operates if a trade name is used. 3. Enter the business address that is used to receive mail by the U.S. Postal Service, if this address is different from the business owner / address. 4. Provide the Federal Employer Identification Number (FEIN) for the business. If one has not been issued, list the Temporary FE IN issued by the Virginia Tax Dept. If you are a sole proprietor with neither, list your social security nu mber; however it is best to obtain a FEIN, given the restrictions on the use of social security numbers. 5. Check the legal status of the business. 6. If a corporation, enter the number of officers. If a LLC, enter the number of paid members. If a partners hip, enter the number of partners. 7. Provide the type of trade or industry in which the business is classified. 8. Enter the business phone number if there is one and the business e - mail if there is one . 9. Provide the n if you have coverage. Enter only No other form of insurance substitutes. Provide the c omplete name of the insurance company or other insuring entity providing i nsurance coverage for the business. Also enter the policy or member number and policy effective dates. Do not list the name of an insurance agent or agency. If you do not know or recall the name of your insurance company or insuring entity, please contact your agent to obtain this informa tion. 10. Out of state employers , please not e, Virginia requires valid Virgi Virginia. For a business that has a valid policy based outside Virginia, if the business either performs or subcontracts wor k in Virginia, the business needs valid Virginia coverage and may usually secure valid Virginia coverage with the proper Virginia Amendatory Endorsement, adding Virginia to Item 3A of the policy. An employer from a monopolistic state must usually obtain se parate coverage from a Virginia licensed insurance carrier. 11. If y ou do not have / on your form you must answer additional questions, please answer whether you have more than t wo employees and whether you hire subcontrac tor s to assist in your work and the number of subcontractor workers. A r esponse to these questions is required. 12. Virginia law requires that every employer who regularly employs more than t wo part - time or full - time employees purchase and maintain workers' compens ation insurance. A business that hires subcontractors to assist in the work of the bus iness or fulfill a contract of the business must count the ing employees to determine if / when coverage is required. This is true even if the A contractor should gather proof of coverage from all subcontractors hired and should not be charged insuran ce premium for subcontractors that have their own coverage. Regardless, a contractor that hires subcontractors with employees must count the when counting total employees and determining when / whether the contractor is required to carry coverage. Virginia coverage requirements for contractors are surprisingly broad and unique. Please take time to review. 13. Commission at 804 205 - 3586. 14. Please ensure that the form is signed, the name of the person signing the form is printed on it and the form is properly dated . 15. at 333 E. Franklin St. , Richmond, VA 232 19 Attn: Insurance Depa rtment Note : The s tate funds of West Virginia and American LegalNet, Inc. www.FormsWorkFlow.com