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Commonwealth of Virginia | Governor

Claimant Registration | Login
Rejection of Coverage Waiver
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Instructions

Dear Customer:

Please have the following information available in order to complete this form:

  • Name and Address of Corporation or LLC
  • Business FEIN (Federal Identification Number or Entity Identification Number)
  • SCC Entity ID # of business (Can be located by contacting the SCC at 1-866-722-2551 or on the web at www.scc.virginia.gov)
  • Officer/Manager information, including last four digits of SSN
  • Executive Officer Title
  • Documentation for Executive Officer titles of Manager/Other showing election or appointment in PDF format
  • Policy Information including complete and accurate insurance carrier, policy number, and policy period dates - Policy information must be on record with the Commission
  • Email address of Employer and Officer for E-signature
1st Step
Done