Workers Compensation Complaint Form

OIC-E362 Rev. 04/2009 TERMINATION OF COVERAGE WV Offices of the Insurance Commissioner Revenue Recovery 1124 Smith Street Room 103 Charleston, WV 25301 Telephone No. (304) 558-1200 Fax No. (304) 558-0671 L 50 The undersigned hereby states that as of the date indicated below, the business as stated below was discontinued or discontinued to have any employees required to be covered with mandatory workers' compensation coverage pursuant to Chapter 23 of the West Virginia Code. Account #________________________________ Employer Name and Address (as listed on account) FEIN #__________________________________ (Name of Business) (Current Phone Number) (Street or PO Box) (City) (State) (Zip) (Permanent Mailing Address, if different from above) 1. The business was ___ Discontinued ___ Closed ___ Sold on the _____day of _____________________, 20____. 2. Last date for employees ____ is ____was the _________ day of _________________________, 20____ -------OR--------3. Employees were terminated due to lack of work (laid off) as of _______ day of _____________________, 20____, and plan to, 4. Rehire on the ______ day of _______________________, 20____. AFFIRMATION: I hereby swear or affirm that to the best of my knowledge and belief these statements and representations are true and accurate. I accept the provisions of the WV Workers' Compensation Act and the Rules promulgated there under, as amended. I further realize that all businesses are subject to inspection and audit. I further understand that in accordance with W.Va. Code §61-3-24e(5), it is a felony to knowingly and willingly make false statements respecting any information required to be provided under the WV Workers' Compensation Code Chapter 23. Upon conviction the individual shall be confined in a penitentiary for up to three years, fined up to $10,000, or both. Signature and title: (Printed Employer Name) (Signature of Owner) (Printed Name of Owner) (Title If Not Owner) (Date) American LegalNet, Inc. www.FormsWorkFlow.com