INSTRUCTIONS FOR COMPLETING THE VWC FORM 61-A
To be completed by the contractor. All information requested is required.
1. Enter the Business owner / Contractor’s name, mailing 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 / contractor’s 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 th e n umb er
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 workers’ compensation insurance information if you have coverage. Enter
only
workers’ compensat io n in surance .
No other form of insurance substitutes. Provide the c omplete name of the insurance company or other insuring entit y p ro vid ing
workers’ compensation 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 Virginia workers’ compensation coverage for work performed in
Virginia. For a business that has a valid policy based outside Virginia, if the business either performs or subcontracts 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 usually o bt ain
separate coverage from a Virginia licensed insurance carrier.
11. If you do not have / list workers’ compensation insurance 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 an d t he
number of subcontractor workers. A response to these questions is required.
12. Virginia workers’ compensation insurance coverage requirements. 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
subcontractor’s employees when count ing employees to determine if / when coverage is required. This is true even if the
subcontractor has their own workers’ compensation coverage.
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
subcontractor’s employees when counting total employees and determining when / whether the contractor is re q u ire d t o c arry
coverage. Virginia coverage requirements for contractors are surprisingly broad and unique. Please take time to review.
13. For workers’ compensation insurance questions please contact the Virginia Workers’ Compensation 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. Return your completed form to the Workers’ Compensation Commission at 333 E. Franklin St., Richmond, VA
23219 Attn: Insurance Department
Note: The state funds of West Virginia and Maryland are not authorized to write workers’ compensation insurance in Virginia.
DO NOT ATTACH ANY DOCUMENTS TO THE CONTRACTOR’S CERTIFICATE.
