Certificate of Workers' Compensation Insurance (Form 61A)

VWC Form: 

 
Electronic filing of the Contractor Certification Form 16A is now available. Click here to complete the form and receive your acknowledgement of compliance.

Pursuant to § 58.1-3714, the governing body of each county, city or town must require every contractor to provide written certification at the time of any application for issuance or reissuance of a business license that such contractor is in compliance with workers’ compensation requirements and will remain in compliance during the effective period of the business license. This form has been developed by the Workers’ Compensation Commission to meet this requirement. Contractors are asked to provide business, contact and workers’ compensation insurance information, if applicable, and to answer a few questions. The completed form assists the Commission in following up with uninsured contractors that may be required to insure under the Act.

Instructions: 

The form is required to be completed fully and with care. The Contractor should list their name, address, business and insurance information. When listing workers’ compensation insurance it is important to list only active workers’ compensation insurance. Listing of Occupational Accident, Employer Liability or other insurance is not a substitute for workers’ compensation.

A Contractor that does not list workers’ compensation coverage is required to answer how many employees they have and whether they hire Independent Contractors or subcontractors with employees to assist in the work. The form must be signed, dated and the Contractor’s name printed. Incomplete forms will be returned to the Contractor for additional information.

This form may be filed electronically with the Commission. To file electronically, the user will need their policy information/declaration page. If this is not available, the user will need to contact his/her agent or broker to obtain the policy number as it was filed with NCCI, the five digit NCCI carrier code assigned to the insurance carrier for which they are insured and the effective and expiration date of the policy.

This form may be filed by mail to 1000 DMV Drive, Richmond, Virginia 23220. Paper filings of this form are manually processed and your acknowledgment returned by mail. You must have your acknowledgement in order to secure your business license or renewal.

Contractors that would like further information concerning Virginia workers’ compensation insurance requirements should review the Contractor’s Information sheet. Contractors with questions may contact the Insurance Department of the Commission by calling (804) 205-3586 or via e-mail at vwcinsurance@workcomp.virginia.gov.

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