VIRGINIA WORKERS’ COMPENSATION COMMISSION 1000 DMV DRIVE, RICHMOND, VA 23220 INSURANCE DEPARTMENT WWW.VWC.STATE.VA.US NOTICE OF CANCELLATION 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, any rewritten policy, or any renewal of a non-renewed policy. Send the original to: File electronically or send single copy to: VA Workers’ Compensation Commission Insurance Department 1000 DMV Drive Richmond, VA 23220 NCCI C/O First Image Data Input Division P.O. Box 7369 London, KY 40742-7369 Insured name and address Carrier Name and address IS THIS A MASTER POLICY ISSUED TO A PROFESSIONAL EMPLOYER ORGANIZATION PROVIDING COVERAGE TO ITS CLIENTS? YES NO (Response required) Carrier NCCI Code Number__________________ Insured S/S # or FEIN_____________________ Type of Cancellation: Non-pay Policy number____________________________ Cancelled by carrier Requested date _____/_____/_____ Policy Period______________to________________ Other Check here if a copy of the Notice is being sent to the insured. 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. Policy Renewed Effective Date of Reinstatement ______/_______/_________ New Policy Number_______________________ Policy Rewritten New Policy Number________________________ ==================================================================================Submitted by:____________________________________ Date:______________________________________ (Must be signed by authorized carrier representative) VWC Form 45H (rev.7/04) American LegalNet, Inc. www.USCourtForms.com