Form Ins 16 PDF Details

In the intricate landscape of workers’ compensation in Virginia, the INS-16 Form serves as a pivotal document for officers and managers who choose to opt-out of workers' compensation coverage. This form is an official declaration made to the Virginia Workers’ Compensation Commission, indicating an individual's choice to reject the benefits normally afforded in the event of an injury by accident under the Virginia Workers’ Compensation Act. It mandates thorough and legible completion, emphasizing the provision of accurate details such as the corporation/LLC name, Federal ID Number, and specific insurance information, among others. Additionally, precise data regarding the officer or manager’s regular salary or wages, if applicable, must be disclosed. The procedure outlined for rejecting coverage not only requires the signature of the officer or manager but also the endorsement of the employer and a witness, ensuring that the decision is well-documented and acknowledged by all relevant parties. The form further provides a framework for an individual’s legal stance on workers’ compensation benefits, making it essential for adhering to state regulations and maintaining clarity in the professional relationship between the employer and the employee. With stringent filing instructions and requirements, the INS-16 Form encapsulates a critical aspect of employment and insurance protocol within Virginia, underscoring the legal nuances that govern workplace safety and compensation.

QuestionAnswer
Form NameForm Ins 16
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesrejection coverage form, virginia 16 coverage form, rejection form online, virginia officer manager rejection coverage form

Form Preview Example

Officer/Manager

 

PLEASE COMPLETE FULLY AND LEGIBLY

Rejection of Coverage

 

 

OR FORM CANNOT BE PROCESSED

Virginia Workers’ Compensation Commission

www.workcomp.virginia.gov

FILING INSTRUCTIONS ON REVERSE SIDE

 

1000 DMV Drive Richmond Virginia 23220

 

 

1-877-664-2566

 

All Information Requested is Required

 

 

 

Corporation /LLC Name:

Address:

Suite/Bldg:

City:

 

State:

 

Zip:

 

 

Corporation:

LLC:

 

 

 

 

 

 

 

 

 

 

 

Business FEIN:

 

 

 

 

 

(Federal ID Number)

 

 

 

 

 

 

 

 

 

 

 

 

VA State Corporation

 

 

 

 

 

Identification

 

 

 

 

 

Number:

 

 

 

 

 

Insurance

Insurance Carrier or

Self Insured Group:

Policy Number:

Policy Period:

Last Name:

First

Name:MI:

Address:

City:

 

 

State:

 

 

Zip:

 

SSN: ________________________________________________

 

 

Last Four Digits Required

 

 

 

 

Officer Title:

President

Secretary

(Check One)

 

 

 

 

 

 

 

 

Vice President

Treasurer

 

 

Manager LLC

Other(*)

Are you paid salary or wages on a regular basis at an agreed amount?

Yes

No

(Response Required)

Pursuant To the provisions of Section 65.2-300 of the Virginia Workers’ Compensation Act, the undersigned hereby rejects the right to claim workers’ compensation benefits for injuries by accident.

Signature of Officer/Manager

Date

Signature of Employer (By)

Date

Signature of Witness

Date

Insurance Agent Information (Optional)

Form #INS-16

Rev. 12/1/12

Agency Name:

Address:

City:

 

State:

 

Zip:

Agent Name:

Agent Telephone:

Agent E-mail:

INSTRUCTIONS

OFFICER/MANAGER

REJECTION OF COVERAGE (VWC FORM 16A)

FILE A SINGLE COPY OF THIS FORM WITH THE VIRGINIA WORKERS’ COMPENSATION COMMISSION.

READ THESE INSRUCTIONS CAREFULLY PRIOR TO COMPLETING THIS FORM.

1.Fill out this form whenever an officer of a corporation or a manager of an LLC elects to reject workers’ compensation coverage for injury or accident under the Virginia Workers’ Compensation Act.

2.The name of the corporation/LLC should be the same as the Charter by which the corporation or LLC is licensed. Use the mailing address used by the corporation or LLC to receive mail by the U.S. Postal Service.

3.Identify the entity by checking corporation or LLC. Provide the employer’s Federal Identification Number and the

State Corporation Commission Identification Number, if applicable.

4.*An Executive Officer means (i) the president, vice-president, secretary, treasurer or other officer, elected or appointed in accordance with the charter and bylaws of a corporation and (ii) the manager elected or appointed in accordance with the articles of organization or operating agreement of a limited liability company.

5.Provide all requested information for the officer/manager rejecting coverage. Officers of a corporation must check “Yes” or “No” to the questions regarding salary or wages.

6.Provide current workers’ compensation insurance coverage information. Do not use such terms as “To Be Assigned,” “Pending” or “Unknown.”

7.Signatures of the employer, officer/manager and the witness are required.

A copy of this notice must be handed to the employer or sent by registered mail. An additional copy must be filed with the Virginia Workers’ Compensation Commission, 1000 DMV Drive, Richmond, VA 23220.

Officer/Manager Rejection of Coverage is continuous unless ended by filing a Termination of Prior Officer Rejection of Coverage (Form 17A).

You may print copies of this form by accessing our website www.workcomp.virginia.gov or request copies by writing to the Commission.

Form #INS-16

Rev. 12/1/12

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