Employers

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. It does not include persons with the title of director, LLC member or chairman.

 This form may be used by employers, insurers, or claims administrators to notify the ADR Department whether an injured worker’s Change in Condition Claim.

• is accepted, accepted in part and denied in part, or denied;
• the reasons for acceptance or denial, and, if denied in whole or in part;
• whether the employer, insurer, or claims administrator consents to issue mediation with the injured worker to try and resolve the claim together, with the help of a mediator, without the need for a hearing.

Mediation participants may use this form to provide feedback to the ADR Program Manager on mediator performance, mediation case management, and suggestions for enhancing program services. The information provided will not be used in any personnel matter.

 Virginia employers lacking coverage may now be reported online via the Virginia Employer Non-Compliance Alerts (VENCA) website operated by the Commission. Click here file a report online.

The Referral for Lack of Coverage Form is offered by the Commission for the public to report an employer suspected of operating in Virginia without workers’ compensation insurance when it is believed the employer is required to carry coverage under the Act.

The occupational disease waiver is used when an employee or prospective employee is affected by or susceptible to a specific occupational disease, but not incapacitated by such disease. The employee or prospective employee may, with approval of the Commission, waive compensation for an aggravation of his/her condition that may result from his/her working or continuing to work in the same or similar occupation for the same employer.

 
Electronic filing of the Rejection of Coverage form is now available. Click here to begin completing the form.

 Electronic filing of the Notice Terminating Prior Rejection of Coverage (Form 17A) is now available. Click here to begin completing the form.

Pursuant to Code of Virginia §§ 65.2-800 and 58.1-3714 signed certifications of insurance coverage are to be provided by the contractor to the localities.

This form is used to report a work place injury to the Commission or to the Insurance Carrier/Claim Administrator depending on the date of injury. For all injuries occurring on or after October 1, 2008, this form should only be used to notify the insurance carrier/claim administrator of a work place injury. For injuries that occurred before October 1, 2008, that have not been reported to the Commission, the employer should use this form to report the injury so that Jurisdiction Claim Number can be assigned.