Form List | Frederick County

Please correct the field(s) marked in red below:

Business License Number Issued by the locality named above:

Applicant's Name:

Applicant's Mailing Address:

Contractor's Home Telephone Number (including area code):

Contractor's Home Telephone Number (including area code):ext.

Business or Trade Name:

Type of Trade or Industry:

Business FEIN or TAX ID/SSN (last 4 digits only):

Business Address:

Business Telephone Number (including area code):

Business Telephone Number (including area code): ext.

Email Address:

Legal Status:

Sole Proprietor

Partnership

Corporation

LLC

Other

Method of insuring for workers' compensation liability.

Insurance carrier licensed in Virginia

Group Self-Insured Association (GSIA) licensed by the State Corporation Commission

Self-Insured with certificatie of authorization issued by the Virginia Workers' Compensation Commissioner

A Professional Employer Organization (PEO) registered in Virginia

Name of Insurance Carrier, Self-Insured, GSIA, or PEO:

Policy, Master Policy, or Certificate Number:

Policy Effective Date and Policy Period:

If Workers' Compensation Insurance is NOT REQUIRED please provide choose a reason:

Less than 3 Employees

Other (Explain below)

If you answered Other above please explain:

To receive a copy of your submission, please fill out your email address below and submit.
Email Address

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Contractor's Certification of Workers' Compensation Liability (Virginia)