Wytheville, VA · Wythe County
Contractor’s Certificate of Workers’ Compensation Insurance (Form 61A)
Contractors complete this certificate to provide workers’ compensation insurance details or answer employee and subcontractor questions for a business license.
What this form is
Contractors complete Form 61A for a business license to report workers’ compensation coverage or answer questions about employees and subcontractors if they do not list insurance. The form requests contractor and business details, trade or industry, insurance carrier and policy information, and relevant employee counts. The applicant signs and dates a certification about the accuracy of the information and the business’s compliance.
Who needs it
Contractors applying for a business license complete this form with their business details and workers’ compensation information or applicable employee and subcontractor answers.
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 document is signed without a notary; the contractor signs and dates the certification under penalty of perjury.
How to submit this form
- 1
Download the Form
Download Form 61A to provide contractor and workers’ compensation information for a business license.
- 2
Complete the Form
Enter the required contractor, business, trade, and insurance details, or answer the employee and subcontractor questions if you do not list coverage.
- 3
Gather Insurance Information
If you have coverage, provide the insuring entity, policy or certificate number, and policy effective and expiration dates.
- 4
Sign and Date
Sign and date the certification, and print the applicant’s name.
- 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 Form 61A used for?
- Contractors use Form 61A to provide business and workers’ compensation information for a business license, or to answer employee and subcontractor questions if they do not list coverage.
- Do I need a notary for Form 61A?
- No. The document has no notary block; the contractor signs and dates the certification 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.
- What information does the form request?
- It asks for contractor and business details, trade or industry, workers’ compensation carrier and policy information, and employee or subcontractor information when coverage is not listed.