Notice Of Change Cancellation Or Non-Renewal
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Notice Of Change Cancellation Or Non-Renewal Form. This is a Virginia form and can be use in Workers Compensation.
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Tags: Notice Of Change Cancellation Or Non-Renewal, 45H-GSIA, Virginia Workers Compensation,
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
Type:
Cancelled by member
Non-pay
Other
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:
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