The Revocation of Prior Rejection of Coverage Form (Form 17A) may be filed by an executive officer or their agent in the event the officer wishes to revoke the officer’s prior rejection of coverage under the Act filed with the Commission. The Form 17A must be completed fully, provided to the employer and filed with the Commission.
The executive officer that elects to revoke a prior rejection of coverage should understand that they are electing to accept coverage under the provisions of the Workers’ Compensation Act, where they had previously chosen to not be covered. The form must be completed fully and accurately. When listing the name of the corporation or LLC the name should be the same as the name in the Charter by which the corporation or LLC is licensed. The business name and the officer’s name listed on the Form 17A should match those listed on the Form 16A when coverage was rejected for the officer/manager. The form must be signed and dated by the officer revoking a prior rejection of coverage and by a representative of the employer.
Once Insurance Department review is completed and the revocation approved, the Commission will notify the officer, the employer and the insurer of the Revocation of Prior Rejection of Coverage. Please note, coverage shall not be extended for injuries that occur within five days of the giving of revocation notice, pursuant to Virginia Code § 65.2-300.
This form may be filed electronically with the Commission provided a Rejection of Coverage (Form 16A) is on file. To file electronically, the user will need the following information:
- Name and Address of Corporation or LLC
- Business FEIN (Federal Identification Number or Entity Identification Number)
- SCC Entity ID # of business (Can be located by contacting the SCC at 1-866-722-2551 or on the web at www.scc.virginia.gov)
- Officer/Manager information, including last four digits of SSN
- Agent’s information (optional)
- Email address of Employer and Officer for E-signature.
This form may be filed by mail or in-person at 333 E. Franklin St., Richmond, VA 23219. This form may also be filed by fax 804-418-4917 or by email to email@example.com.
For questions concerning the Rejection of Coverage form please call the Insurance Department of the Commission at (804) 205-3586 or email firstname.lastname@example.org.