Fill and Sign the Revenue Recovery West Virginia Offices of the Insurance Form

OIC-E362 TERMINATION OF COVERAGE L 50 Rev. 3/2013 W V Offices of the Insurance Commissioner Revenue Recovery P. O. Box 50540 Charleston, WV 2530 5 Telephone No. (304) 558 -1200 Fax No. (304) 558-067 1 The undersigned hereby states that as of the date in dicated below, the business as stated below was dis continued or discontinued to have any employees required to be covered with m andatory workers’ compensation coverage pursuant to Ch apter 23 of the W est Virginia Code. Account #________________________________ Employer Name and Address (as listed on account) FEIN #__________________________________ (Name of Business) (Current Phone Number) (Street or PO Box) (City) (State) (Zip) (Permanent Mailing Address, if different from above) ONLY COMPLETE BELOW WHAT APPLIES TO YOUR SIT UATION. IF NON E APPLIES, ATTACH LETTER EXPLAINING OR WRITE IN MARGINS. 1.The business was ___ Discontinued ___ Closed ___ Sold on the _____ day of _____________________, 20____. SOLD TO: ___________________________________________ __. 2. Last date for employees was the _________ day of _________________________, 20____ 3. Rehire on the ______ day of _______________________, 20____. AFFIRMATION: I hereby swear or affirm that to the best of my knowled ge and belief these statements and representations are true and accurate. I accept the provisions of the WV Workers’ Compensation Act and the Rules promulgated there under, as amended. I further realize that all businesses are subject to ins pection and audit. I further understand that in accordance with W.Va. Co de §61-3-24e(5), it is a felony to knowingly and willingly make false statements respecting any information re quired to be provided under the WV Workers’ Compensation Code Chapter 23. Upon conviction the individual shall be confined in a penitentiary for up to three years, fined up to $10,000, or both. Signature and title: (Printed Employer Name) (Signature of Owner) (Printed Name of Owner) (Title If No t Owner) (Date)