Notice Terminating Prior Rejection of Coverage (Form 17A)

The executive officer that elects to revoke a prior rejection of coverage should understand that they are electing to accept coverage under the provisions of the Workers’ Compensation Act, where they had previously chosen to not be covered. The form must be completed fully and accurately. When listing the name of the corporation or LLC the name should be the same as the name in the Charter by which the corporation or LLC is licensed. The business name and the officer’s name listed on the Form 17A should match those listed on the Form 16A when coverage was rejected for the officer/manager. The form must be signed and dated by the officer revoking a prior rejection of coverage and by a representative of the employer.

The Form 17A may be submitted to the Insurance Department of the Commission via mail to: Insurance Department Virginia Workers’ Compensation Commission 333 E. Franklin St., Richmond, VA 23219

Alternatively, the form may be submitted by fax to 804-418-4917.

Once Insurance Department review is completed and the revocation approved, the Commission will notify the officer, the employer and the insurer of the Revocation of Prior Rejection of Coverage. If agent information is provided to the Commission, the agent is notified of form processing as well. Please note, coverage shall not be extended for injuries that occur within five days of the giving of revocation notice, pursuant to Virginia Code § 65.2-300.

For questions concerning the Revocation of Prior Rejection of Coverage form please call the Insurance Department of the Commission at (804) 205-3586 or email vwcinsurance@workcomp.virginia.gov.