This report is for Individual Public-Municipal Self-Insurers to report their payroll to the Commission, broken down by NCCI payroll classifications for tax assessment purposes.
The Individual Public-Municipal Self-Insurer will complete the form, have it notarized and return the original copy to the Commission on or before March 15th.
This form may be filed with the Commission in the following ways:
- MAIL: Mail the completed form to 333 E. Franklin St., Richmond, VA 23219.
- IN PERSON: Bring the completed form to any of our VWC Office Locations.
For questions about or assistance with completing this form, please contact Amy M. Pearson, Assistant Financial Officer, at 804-482-7042 or by email at email@example.com.