ࡱ> $&#q  bjbjt+t+ %AA] RW}$ L=="""" "f"  "DGS-30-076 CO-9a (Rev. 05/02) Page 1 of 1 COMMONWEALTH OF VIRGINIA WORKERS' COMPENSATION Certificate of Coverage Section 2.2-4332, Code of Virginia, requires construction contractors and subcontractors to obtain and maintain workers' compensation insurance while performing work on behalf of the Commonwealth of Virginia, its departments, institutions, or agencies. This same requirement applies on behalf of local governments. Evidence of coverage must be provided prior to commencement of Work. This form must be completed and returned to the organization contracting the Work. The undersigned organization stipulates that it: A. has workers' compensation insurance and is in compliance with the Workers' Compensation statutes of the Commonwealth of Virginia. _____ Yes _____ No Insurance Company ____________________________________ Policy expiration date __________________________________ B. is self insured for workers' compensation. _______ Yes Title of Construction Contract: ___________________________________________________ _____________________________________________________________________________ Contract Number: ______________________________________________________________ Signed by: _____________________________________ Title:_____________________________________ Firm Name: _____________________________________ Address:_____________________________________ _____________________________________ _____________________________________ <=k >*CJ5CJ5CJ$CJCJ5 <=Vl \]*b/~dhd8d80d8$dd$d<=Vl \]*b/~ - ^ " - ^ $$dhdh #0P/ =!"#$% [4@4Normal1$CJhmH nH <A@<Default Paragraph Font4&@4Footnote Reference     DGS)C:\windows\TEMP\FrontPageTempDir\co9a.wpd Brian HudnallC:\WINDOWS\DESKTOP\CO9a.doc Brian Hudnall3C:\WINDOWS\DESKTOP\Forms\DGS-30-076_02-01_CO-9a.doc Brian Hudnall<C:\WINDOWS\DESKTOP\VPPA Form Mods\DGS-30-076_05-02_CO-9a.doc Brian Hudnall<C:\WINDOWS\DESKTOP\VPPA Form Mods\DGS-30-076_05-02_CO-9a.doc@HP LaserJet 2100 Series PCL 6\\DEBFS1\COST_GROUPhpbxlbHP LaserJet 2100 Series PCL 6HP LaserJet 2100 Series PCL 6, ttghjil d(Untitled),HP LaserJet 2100 Series PCL 6, ttghjil d(Untitled),hc@G:Times New Roman5Symbol3& :Arial" h1:RfeF $ GDGS Brian HudnallOh+'0X    ,8@HPGssDGSGS Normal.dotBrian Hudnallo4iaMicrosoft Word 8.0@G@{W@v՜.+,D՜.+,, hp|  COV 1 G Title 6> _PID_GUIDAN{46FE7380-00D2-11D4-AA75-00C04F2768BB}  !"%Root Entry FYXl'1Table WordDocument%SummaryInformation(DocumentSummaryInformation8CompObjjObjectPool  FMicrosoft Word Document MSWordDocWord.Document.89q