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Contractor s Certificate of Workers Compensation Insurance (Form 61-A) www.workcomp.virginia.gov INSTRUCTIONS ON REVERSE SIDE File completed form at local office where business license is obtained
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How to fill out form 61 a
How to fill out VA VWC 61-A
01
Gather personal information: Collect your Social Security number, address, and contact information.
02
Fill out the claimant's section: Include your name, contact details, and the date of the injury.
03
Describe the incident: Provide a detailed account of how the injury occurred, including date, time, and location.
04
Complete the medical information: Include details of any medical treatment received and the names of healthcare providers.
05
Document wages: Input your earnings prior to the injury, including the frequency of pay.
06
Sign and date the form: Make sure to sign the form to validate your claim.
07
Submit the form: Send the completed form to the appropriate VA office or your employer as indicated.
Who needs VA VWC 61-A?
01
Employees who have sustained work-related injuries or illnesses.
02
Veterans seeking compensation for service-connected disabilities impacting their ability to work.
03
Individuals filing for benefits related to specific workplace incidents covered by VA regulations.
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What is VA VWC 61-A?
VA VWC 61-A is a form used in Virginia for reporting workers' compensation claims.
Who is required to file VA VWC 61-A?
Employers who have an injured worker must file VA VWC 61-A to report the incident and any related compensation claims.
How to fill out VA VWC 61-A?
To fill out VA VWC 61-A, provide the necessary information about the injured employee, the incident details, and any relevant compensation data.
What is the purpose of VA VWC 61-A?
The purpose of VA VWC 61-A is to document and report workplace injuries to ensure compliance with workers' compensation laws.
What information must be reported on VA VWC 61-A?
Information that must be reported includes the employee's details, nature of the injury, date of the incident, and any compensation information.
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