Contractor’s Certification of Insuring Liability for Workers’ Compensation In Virginia Complete and file this form with each Virginia locality where you have applied for or are renewing a business license. Do not attach any documents to this certificate. Name of City, Town or County in Virginia Issuing License: _________________________ (A separate certificate must be filed with each locality in which you obtain a license.) Business License Number Issued by the locality named above: _______________________ Name of Contractor: __________________________________________________________ Contractor’s Address: _________________________________________________________ Contractor’s FEIN OR SSN: _____________________________________________________ Contractor’s Telephone Number: (____) __________________________________________ Legal Status: (Check One) Sole Proprietor Partnership Corporation LLC Other (specify) __________________________________________________________________ Method by which contractor’s liability for workers’ compensation is insured: Insured by an insurance carrier licensed to do business in Virginia: (The Maryland Injured Workers Fund and the West Virginia Fund are not licensed to write W.C. coverage in Virginia.) Name of Carrier: _________________________________________________________________________________________________ Policy Number: _______________________________________ Policy Effective Date: _______________________________________ A member of a group self-insured association licensed to do business in Virginia: Name of Self-Insured Group: ______________________________________________________________________________________ Member Number: _______________________________________Effective Date: ___________________________________________ Self-Insured by the Virginia Workers’ Compensation Commission. Member Number: Insured under a master policy of a licensed Professional Employer Organization. Name of PEO: _____________________________ Workers’ Compensation Insurance is not required. State Reason: _______________________________________________________ Under penalty of law, the undersigned certifies he/she is duly authorized by the business license applicant to execute this certificate, and the business named above is in compliance with §65.2-800 et seq. of the Virginia Workers’ Compensation Act, and will remain in compliance with the law during the effective period of the business license. Signature of Applicant or Authorized Agent: ______________________________________ Print Name of Applicant or Authorized Agent: _____________________________________ Date: __________________ V.W.C. Form 61-A has been prepared and distributed by The Virginia Worker's Compensation Commission to local licensing authorities for their use in compliance with §58.1-3714, Code of Virginia. American LegalNet, Inc. www.USCourtForms.com VWC Form No. 61A (rev. 7/02) INSTRUCTIONS FOR COMPLETION OF VWC FORM 61A CONTRACTOR’S CERTIFICATION Item 1 – To be completed by the official issuing the business license. 1. Circle one. City, Town or County. Provide the name of locality issuing the license. Provide business license number including any prefix or suffix. Item 2 –7 – To be completed by the contractor. 2. The name of the contractor must be the same as the name insured on the workers’ compensation insurance policy. Sole-proprietors and partners should include the name of the sole-proprietor and all partners as well as the trade name under which the business operates. Provide the complete address used to receive mail by the U.S. Postal Service. 3. Provide the federal identification number or social security number. This information should also match the information on the workers’ compensation policy. 4. Check or mark the legal status of the business. 5. Provide the complete name of the insurance company or self-insured group that insures the workers’ compensation liability. If you are a client of a licensed Professional Employer Organization (PEO) and are insured under its master policy, provide the name of the PEO. Do not use the name of an insurance agency. If the name of the insurance company is unknown, contact the agent for this information. The complete policy number or self-insured member number, including any prefix or suffix, must be shown. If a question arises regarding whether workers’ compensation coverage is required, consult one or more of the following resources: (1) the brochure provided, (2) an insurance agent, (3) an attorney familiar with workers’ compensation, or (4) the Insurance Department at the Workers’ Compensation Commission at (804) 367-2075. 6. Sign and print the name of the person signing the form. 7. Date the form and present it to the licensing authority. Note: The state funds of West Virginia and Maryland are not authorized to write workers’ compensation insurance in Virginia. DO NOT ATTACH ANY DOCUMENTS TO THE CONTRACTOR’S CERTIFICATE. American LegalNet, Inc. www.USCourtForms.com