Broadway, VA · Rockingham County
Contractor’s Certificate of Workers’ Compensation Insurance (Form 61A)
Contractors complete this certificate to provide business, worker, and workers’ compensation insurance information for a business license application.
What this form is
Contractors use Form 61A to certify information about their business and workers’ compensation coverage for a business license application. The form asks for business and contact details, business structure, trade or industry, insurance carrier and policy information, or employee and subcontractor details if coverage is not listed. The contractor signs and dates the certification.
Who needs it
A contractor applying for a business license completes this form to report workers’ compensation coverage or answer questions about employees and subcontractors.
How to submit it
Return the completed form to your local Commissioner of the Revenue or the appropriate official of a county, city, or town.
About notarization
This form is signed and dated without a notary; the contractor certifies under penalty of perjury that the information is correct and the business is compliant.
How to submit this form
- 1
Download the Form
Download the Contractor’s Certificate of Workers’ Compensation Insurance (Form 61A).
- 2
Complete the Contractor Details
Provide the requested business, contact, identification, business structure, and trade or industry information.
- 3
Enter Workers’ Compensation Information
List coverage and policy details, or answer the questions about employees and subcontractors if you do not list insurance.
- 4
Sign and Date the Form
Sign and date the certification as the contractor applicant.
- 5
Return the Form
Return it to your local Commissioner of the Revenue or the appropriate official of a county, city, or town.
Frequently asked questions
- What is the Contractor’s Certificate of Workers’ Compensation Insurance?
- Form 61A records a contractor’s business details and workers’ compensation coverage information, or asks about employees and subcontractors when coverage is not listed.
- Who completes Form 61A?
- The instructions say the contractor completes the form. It is used for a business license application and requires information about the business and its workers’ compensation status.
- Do I need a notary for the Contractor’s Certificate of Workers’ Compensation Insurance?
- No. The form has no notary block; the contractor signs and dates it and certifies the information under penalty of perjury.
- How do I submit Form 61A?
- Return the completed form to your local Commissioner of the Revenue or the appropriate official of a county, city, or town.