Contractor's Certification of Workers' - Virginia Workers - winchesterva 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the locality issuing the business license. Specify whether it is a City, Town, or County and provide the business license number.
3. Fill in your name as the contractor, along with your mailing address and phone number. Ensure all information is complete and legible.
4. Provide your business or trade name, including any applicable legal status such as LLC or Sole Proprietor. Include your Federal Employer Identification Number (FEIN) or Social Security Number if necessary.
5. List the name of your workers’ compensation insurance carrier, along with the policy number and effective dates. If you are self-insured or part of a PEO, include that information accordingly.
6. If claiming that workers’ compensation is not required, check the appropriate box and provide a reason. Indicate whether you hire independent contractors or subcontractors.
7. Finally, sign and date the form, ensuring that you print your name clearly before submitting it to the licensing authority.

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