Do I need a notary for the Contractor’s Certification?

No. The form asks the applicant or authorized agent to sign and date it, but has no notary block. It also instructs filers not to attach documents.

Who completes the contractor certification?

The contractor completes the contractor sections. The licensing official completes the locality and business license information identified in the form instructions.

What information does the form ask for?

It asks for contractor and business details, legal status, workers’ compensation insurance or self-insurance information, or the reason coverage is not required, plus a signature and date.

Farmville, VA · Cumberland County

No notary required

Contractor’s Certification of Insuring Liability for Workers’ Compensation in Virginia

Contractors complete this certificate to document workers’ compensation coverage or explain why coverage is not required when applying for or renewing a business license.

What this form is

This certificate documents a contractor’s workers’ compensation insurance or states why coverage is not required. The form says to complete and file it with each Virginia locality where the contractor has applied for or is renewing a business license. It asks for business and license details, legal status, insurance or self-insurance information, and an authorized signature and date.

Who needs it

Contractors applying for or renewing a business license in a locality must file a separate certificate with each locality where they obtain a license.

How to submit it

Complete the form and present it to the licensing authority. File a separate certificate with each locality where you have applied for or are renewing a business license.

About notarization

This certificate is signed and dated without a notary; do not attach any documents to it.

How to submit this form

1
Download the Form
Download the Contractor’s Certification PDF.
2
Complete the Contractor Sections
Provide the requested business, legal status, and workers’ compensation coverage information.
3
Sign and Date
The applicant or authorized agent signs and prints their name, then dates the form.
4
Submit to the Licensing Authority
Present the form to the licensing authority. File a separate certificate with each locality where you have applied for or are renewing a business license.

Frequently asked questions

Do I need a notary for the Contractor’s Certification?: No. The form asks the applicant or authorized agent to sign and date it, but has no notary block. It also instructs filers not to attach documents.
Who completes the contractor certification?: The contractor completes the contractor sections. The licensing official completes the locality and business license information identified in the form instructions.
How do I submit the certification?: Present the completed form to the licensing authority. File a separate certificate with each locality where you have applied for or are renewing a business license.
What information does the form ask for?: It asks for contractor and business details, legal status, workers’ compensation insurance or self-insurance information, or the reason coverage is not required, plus a signature and date.

Need something notarized?

This Contractor’s Certification of Insuring Liability for Workers’ Compensation in Virginia doesn’t need a notary — but if you have another Farmville form that does, a commissioned online notary can help.