Electronic filing of the Rejection of Coverage form is now available. Click here to begin completing the form.
The Rejection of Coverage form may be filed by an executive officer or their agent should the officer elect to exclude himself or herself from coverage under the Act. An executive officer means (i) president, vice-president, secretary, treasurer or other officer, elected or appointed in accordance with the charter and bylaws of a corporation and (ii) the manager elected or appointed in accordance with the articles of organization or operating agreement of a limited liability company. (Please note Form LLC-1011 utilized by the State Corporation Commission is not sufficient evidence to prove election or appointment as a Manager.) It does not include persons with the title of director, LLC member or chairman. An officer may exclude himself or herself from coverage for injury or death by accident, but not for occupational disease. A Rejection of Coverage filing is commonly performed in order to reduce the insurance premium on the business workers’ compensation insurance policy.
The executive officer that elects to reject coverage should understand the hazards of their employment and should understand that by filing this form they are rejecting the right to claim workers’ compensation benefits in the event of work injury or death by accident. The form must be completed fully and accurately and must be signed by the officer rejecting coverage and by a representative of the employer. A workers’ compensation policy must be current to reject coverage from. The business should be active in State Corporation Commission. For an officer that is rejecting from a policy based out of state the business need not be active in Virginia State Corporation Commission, however, the policy must have valid Virginia coverage. Executive officer status will be verified by the Commission. For a corporate officer, status is verified in State Corporation Commission. The officer may present separate documentation if it is more current. For LLC managers, their manager status must be supported by articles of organization, the operating agreement or other documentation indicating that the individual filing for rejection was elected or appointed as a manager of the LLC. The form must be provided to the employer and dated and must be signed by the officer and dated. The notice must also be filed with the Commission where it is reviewed to ensure that all information is accurate. Once review is completed and the exclusion approved, the Commission will notify the officer, the employer and the insurer of the Rejection of Coverage. If agent information is provided to the Commission, the agent is notified of form processing as well.
The effective date of a rejection of coverage filing, per the statute, section 65.2-300 shall be as of the last to occur of (i) the date of the inception of the policy or (ii) the delivery of such notice to the employer as provided in this subsection. A Rejection of Coverage is deemed continuous unless a Revocation of Prior Rejection of Coverage (Form 17A) is filed.
This form may be filed electronically with the Commission. 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
- Executive Officer Title
- Documentation for Executive Officer titles of Manager/Other showing election or appointment in PDF format
- Policy Information including complete and accurate insurance carrier name, carrier code, policy number, and policy period dates. Policy information can be located on the declaration/information page of the policy. If this information is not available, the user will need to contact his/her agent/broker to obtain this information. Policy information must be on record with the Commission.
- 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.