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 email@example.com.