The Revocation of Prior Rejection of Coverage Form (Form 17A) may be filed by an executive officer or their agent in the event the officer wishes to revoke the officer’s prior rejection of coverage under the Act filed with the Commission. The Form 17A is a one page form that must be completed fully, provided to the employer and filed with the Commission.
The executive officer that elects to revoke a prior rejection of coverage should understand that they are electing to accept coverage under the provisions of the Workers’ Compensation Act, where they had previously chosen to not be covered. The form must be completed fully and accurately. When listing the name of the corporation or LLC the name should be the same as the name in the Charter by which the corporation or LLC is licensed. The business name and the officer’s name listed on the Form 17A should match those listed on the Form 16A when coverage was rejected for the officer/manager. The form must be signed and dated by the officer revoking a prior rejection of coverage and by a representative of the employer.
The Form 17A may be submitted to the Insurance Department of the Commission via mail to:
Virginia Workers’ Compensation Commission
1000 DMV Drive
Richmond, VA 23220
Alternatively, the form may be submitted by fax to (804) 367-2239 or by email to email@example.com.
Once Insurance Department review is completed and the revocation approved, the Commission will notify the officer, the employer and the insurer of the Revocation of Prior Rejection of Coverage. If agent information is provided to the Commission, the agent is notified of form processing as well. Please note, coverage shall not be extended for injuries that occur within five days of the giving of revocation notice, pursuant to Virginia Code § 65.2-300.
For questions concerning the Revocation of Prior Rejection of Coverage form please call the Insurance Department of the Commission at (804) 205-3586 or email firstname.lastname@example.org.