Annual Report of Self-Insurer's Payroll (Form 26)

Download Annual Report of Self-Insurer's Payroll (Form 26)

 This report is for Individual Private Self-Insurers to report their payroll to the Commission, broken down by NCCI payroll classifications for tax assessment purposes.

The Individual Private 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 amy.pearson@workcomp.virginia.gov.