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Form 17A - Revocation of Prior Rejection of Coverage
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Instructions

The Revocation of Prior Rejection of Coverage Form (Form 17A) should be filed when an officer wishes to revoke the officer's prior rejection of coverage under the Workers' Compensation Act (Act) filed with the Commission. The executive officer that elects to revoke a prior rejection of coverage should understand that they are now electing to accept coverage under the provisions of the Act.

Dear Customer:

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

  • An active approved Rejection of Coverage form (Form 16A) must be on file with the Commission and have been processed on or after February 1, 2009 in order to submit a Revocation of Prior Rejection of Coverage form (Form 17A) electronically. If the 16A was filed prior to February 1, 2009, a paper submission should be filed with the Commission.
  • 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
  • Email address of Employer and Officer for E-signature
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