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Rejection Of Coverage Form. This is a Virginia form and can be use in Workers Compensation.
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Tags: Rejection Of Coverage, 16A, Virginia Workers Compensation,
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 ยง65.2-300 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.)
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