Notice Terminating Prior Rejection Of Coverage Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Notice Terminating Prior Rejection Of Coverage Form. This is a Virginia form and can be use in Workers Compensation.
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Tags: Notice Terminating Prior Rejection Of Coverage, 17A, Virginia Workers Compensation,
Virginia Workers' Compensation Commission
1000 DMV Drive
Richmond, Va 23220
NOTICE TERMINATING PRIOR REJECTION OF COVERAGE
UNDER THE VIRGINIA WORKERS' COMPENSATION ACT
EMPLOYER INFORMATION
q
______________________________
Corporate/L.L.C. Name
q
Corporation
OR
L.L.C.
(Check One)
______________________________
Street Address
______________________________
Federal Identification Number
______________________________
______________________________
City
Va. State Corporation Number
State
Zip Code
=============================================
OFFICER/MANAGER TERMINATING PRIOR REJECTION OF COVERAGE
______________________________
______________________________
Name (Last, First and Middle Initial)
Social Security Number
______________________________
Street Address
______________________________
City
State
Zip Code
______________________________
Title of Officer (Manager, if applicable)
=============================================
This is Notice that the undersigned hereby terminates the rejection of the right to claim compensation benefits on account of injuries
by accident sustained under Virginia Workers’ Compensation Act as provided in §65.2-300 and, in accordance with §65.2-300,
hereby accepts the provisions of the Act.
_____________________________
_________________
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. 17A (rev, 1/1/99)
(See opposite side for instructions to complete this form.)
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