Virginia Workers' Compensation Commission 1000 DMV Drive Richmond, Va 23220 REJECTION OF COVERAGE UNDER THE VIRGINIA WORKERS' COMPENSATION ACT EMPLOYER INFORMATION ______________________________ q Corporation Corporate/L.L.C. Name OR ______________________________ Street Address q L.L.C. (Check One) ______________________________ ______________________________ Federal Identification Number City ______________________________ State Zip Code Va. State Corporation Number =========================================== OFFICER/MANAGER REJECTING COVERAGE ______________________________ ______________________________ Name (Last, First and Middle Initial) Social Security Number ______________________________ ______________________________ Street Address Date of Hire (Month/Day/Year) ______________________________ City State Are you paid a salary or wages on a regular basis at an Zip Code agreed upon amount? Officers Only) q Yes q No (Corporate ______________________________ Title of Officer (Manager, if applicable) =========================================== Current Coverage Information __________________________ ________________ Name of Insurance Carrier or Self-Insured Group Policy Number ________to __________ Policy Period =========================================== Pursuant to the provisions of §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/Member Date _____________________________ _________________ Signature of Employer Date (By) _____________________________ _________________ Witness Date 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. VWC Form No. 16A (rev, 1/1/99) (See opposite side for instructions to complete this form.) American LegalNet, Inc. www.USCourtForms.com American LegalNet, Inc. www.USCourtForms.com