To be completed by the contractor. All information requested is required.
1. Enter the B ailing address and phone number, all information is required.
2. Enter the complete name of business. Additionally list t he trade name under which the business operates if a trade name is used.
3. Enter the business address that is used to receive mail by the U.S. Postal Service, if this address is different from the business
owner /
address.
4. Provide the Federal Employer Identification Number (FEIN) for the business. If one has not been issued, list the Temporary FE IN
issued by the Virginia Tax Dept. If you are a sole proprietor with neither, list your social security nu mber; howe ver it is be st t o
obtain a FEIN, given the restrictions on the use of social security numbers.
5. Check the legal status of the business.
6. If a corporation, enter the number of officers. If a LLC, enter the number of paid members. If a partnership, enter the number
of partners.
7. Provide the type of trade or industry in which the business is classified.
8. Enter the business phone number if there is one and the business e-mail if there is one.
9. Provide the
n if you have coverage. Enter
No other form of insurance substitutes. Provide the c omplete name of the insurance company or other insuring entit y pro vid in g
insurance coverage for the business. Also enter the policy or member number and policy effective dates.
Do not list the name of an insurance agent or agency. If you do not know or recall the name of your insurance company or
insuring entity, please contact your agent to obtain this information.
10. Out of state employers, please note, Virginia requires valid Virgi
Virginia. For a business that has a valid policy based outside Virginia, if the business either performs or subcont racts wor k in
Virginia, the business needs valid Virginia coverage and may usually secure valid Virginia coverage with the proper Virginia
Amendatory Endorsement, adding Virginia to Item 3A of the policy. An employer from a monopolistic state must usu ally o bt ain
separate coverage from a Virginia licensed insurance carrier.
11. If you do not have /
on your form you must answer additional questions,
please answer whether you have more than two employees and whether you hire subcontractors to assist in your w o rk and t he
number of subcontractor workers. A response to these questions is required.
12.
Virginia law requires that every employer who
regularly employs more than t wo part-time or full-time employees purchase and maintain workers' compensation insurance. A
business that hires subcontractors to assist in the work of the business or fulfill a contract of the business must count the
ing employees to determine if / when coverage is required. This is true even if the
A contractor should gather proof of coverage from all subcontractors hired and should not be charged insurance premium for
subcontractors that have their own coverage. Regardless, a contractor that hires subcontractors with employees must count t he
when counting total employees and determining when / whether the contractor is re quire d t o c arry
coverage. Virginia coverage requirements for contractors are surprisingly broad and unique. Please take time to review.
13.
Commission at 804 205-3586.
14. Please ensure that the form is signed, the name of the person signing the form is printed on it and the form is properly dated.
15.
at 333 E. Franklin St., Richmond, VA
23219 Attn: Insurance Department
Note: The state funds of W est Virginia and
