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Commonwealth of Virginia
Workers’ Compensation Commission

Contractor’s Certification of Insuring Liability for Workers’ Compensation in Virginia

*****Read the certification prior to completing this form*****

This form is to be filed by the locality with the Workers’ Compensation of Virginia: (Insurance Department, VA Workers’ Compensation Commissioner, at 1000 DMV DRIVE, RICHMOND, VA 23220)

City, Town or County of:

Business License Number:

Name of Contractor:

Contractor’s Address:

Federal ID # or SS#:

Legal Status: Sole Proprietor Partnership Corporation LLC

Other (specify)

Method by which contractor’s liability for workers’ compensation is insured:

Insured by an insurance carrier licensed to do business in Virginia:

Name of Carrier:

Policy Number: Policy Effective Date:

A member of a group self-insured association licensed to do business in Virginia:

Name of Self-Insured Group:

Member Number: Member Effective Date:

Workers’ Compensation Insurance Coverage is not required:

State Reason:

Under penalty of law, the undersigned certifies he/she is duly authorized by the business license applicant to execute this certificate, and that the business name above is in compliance with §65.2-800 et seq., Code of Virginia, and will remain in compliance with the statute at all times during the effective period of the business license.

Signature of Applicant or Authorized Agent:

______________________________________________________

Print Name of Applicant or Authorized Agent:

______________________________________________________

 

***** Certification*****

§ 58.1-3714, Code of Virginia, provides in pertinent part:

B. 1. The governing body of any county, city or town shall not issue or reissue a business license under this chapter to any contractor who (i) has not obtained or is not maintaining workers’ compensation coverage for his employees and (ii) at the time of application for such issuance or re-issuance, is required to obtain or maintain such coverage pursuant to Chapter 8 (§ 65.2-800 et. Seq.) of Title 65.2.

  1. Each such governing body shall require every contractor to provide written certification at the time of any application for issuance or re-issuance of a business license that such contractor is in compliance with the provisions o Chapter 8 of Title 65.2 and will remain in compliance with such provisions at all times during the effective period of any such business license.
  2. The governing body of any county, city or town shall forward such signed certification to the Virginia Workers’ Compensation Commission, who shall conduct periodic audits of selected contractors to whom such body has issued business licenses to ensure the compliance of such contractors with the requirements of this subsection and th4e provisions of Chapter 8 of Title 65.2.
  3. Any person who knowingly presents or causes to be presented to the governing body a false certificate shall be guilty of a Class 3 misdemeanor.

D. For the purpose of license taxation pursuant to §58.1-3703, the term "contractor" means any person, firm or corporation

  1. Accepting or offering to accept orders or contracts for doing any work on or in any building or structure, requiring the use of paint, stone, brick, mortar, wood, cement, structural iron or steel, sheet iron, galvanized iron, metallic piping, tin, lead, or other metal or any other building material:
  2. Accepting or offering to accept contracts to do any paving, curbing or other work on sidewalks, streets, alleys, or highways, or public or private property, using asphalt, brick, stone, cement, concrete, wood or any composition;
  3. Accepting or offering to accept an order for or contract to excavate earth, rock, or other material for foundation or any other purpose or for cutting, trimming or maintaining right-of-way;
  4. Accepting or offering to accept an order or contract to construct any sewer of stone, brick, terra cotta or other material;
  5. Accepting or offering to accept orders or contracts for doing any work on or in any building or premises involving the erecting, installing, altering, repairing, servicing, or maintaining electric wiring, devices or appliances permanently connected to such wiring, or the erecting, repairing or maintaining or electric wiring, devices or appliances permanently connected to such wiring, or the erecting, repairing or maintaining of lines for the transmission or distribution of electric light and power; or
  6. Engaging in the business plumbing and steam fitting.

If you are uncertain regarding your legal duty to obtain and maintain a policy of workers’ compensation insurance, you are encouraged to consult the following before executing this certificate:

  1. Workers’ Compensation Requirements for Employers in Virginia, published by the Virginia Workers’ Compensation Commission and available at no charge from the commission or from your local Commissioner of Revenue:
  2. Your insurance agent or attorney;
  3. The Insurance Department of the Virginia Workers’ Compensation Commission, which may be reached by telephone at (804) 367-2071.

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