Officer Manager Rejection Of Coverage {16A}

OFFICER/MANAGER REJECTION OF COVERAGE. This form is used by executive officers or managers of corporations or limited liability companies (LLCs) in Virginia to formally reject coverage under the state's workers' compensation insurance laws. By submitting this form, the officer or manager chooses to waive their right to claim workers' compensation benefits for work-related injuries. The form must be completed in its entirety and submitted to the Virginia Workers' Compensation Commission. It requires details about the employer, including the corporation or LLC's name, address, employer identification number (FEIN), and active workers' compensation insurance policy information. The officer or manager must also provide their personal information, such as name, title, address, and the last four digits of their social security number. If the individual holds a title other than president, vice president, secretary, or treasurer in a corporation, they must include supporting documents, such as the corporate charter or bylaws, to show their officer status. For managers of a multiple-member LLC, articles of organization or an operating agreement must be attached to prove their appointment. The form requires both the officer/manager and the employer to sign and date it, acknowledging the rejection of coverage. This rejection remains in effect until a termination of prior officer rejection of coverage (Form 17A) is filed. The form may be submitted by mail, hand delivery, fax, or electronic filing through the Virginia Workers' Compensation Commission website. www.FormsWorkflow.com