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.
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.
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.
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
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:
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;
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;
Accepting or offering to accept an order or contract to construct any
sewer of stone, brick, terra cotta or other material;
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
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:
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:
Your insurance agent or attorney;
The Insurance Department of the Virginia Workers’ Compensation Commission,
which may be reached by telephone at (804) 367-2071.
