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Commonwealth of Virginia | Governor

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Form 61A - Certificate of Workers' Compensation Insurance
Important Message

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You will need your policy information/declaration page to complete this form. If this is not available to you, you will need to contact your agent/broker to obtain your policy number as it was filed with NCCI, the five digit NCCI carrier code assigned to the insurance carrier you are insured with and the effective and expiration date of your policy.

For Workers' Compensation Insurance Information for employers click here.