W. Va. Code R. § 85-10-9
If any provision of this rule or the application thereof to any entity or circumstance shall be held invalid, such invalidity shall not affect the provisions or the applications of this rule which can be given effect without the invalid provisions or application and to this end the provisions of this rule are declared to be severable.
NOTIFICATION REQUEST
DEFAULT OF SUBCONTRACTOR
The undersigned primary contractor hereby notifies the workers' compensation commission that it has entered into a subcontract(s) and that it desires to receive notice from the workers' compensation commission if the subcontractor(s) defaults on any payments due to the workers' compensation commission.
(Please provide the following information:)
PRIMARY CONTRACTOR'S NAME:_____________________________________________________
ADDRESS TO WHICH NOTICES ARE TO BE SENT:_______________________________________
PRIMARY CONTRACTOR'S POLICY NUMBER:___________________________________________
PRIMARY CONTRACTOR'S FEIN1 NUMBER: ____________________________________________
SUBCONTRACTOR'S COMPLETE FORMAL NAME (AND INCLUDE ANY TRADE NAME OR TRUE NAME OR A.K.A.)
_____________________________________________________________________________________
SUBCONTRACTOR'S ADDRESS: _______________________________________________________
_____________________________________________________________________________________
SUBCONTRACTOR'S POLICY NUMBER:________________________________________________
SUBCONTRACTOR'S FEIN 1 NUMBER:__________________________________________________
GIVE A BRIEF DESCRIPTION OF CONTRACT INCLUDING WORKSITE(S):
_____________________________________________________________________________________
_____________________________________________________________________________________
EXPECTED LENGTH OF THE CONTRACT (BEGINNING DATE & ENDING DATE:
_____________________________________________________________________________________
(Additional sheets may be attached for additional subcontractors.)
DATE: ________________SIGNATURE:__________________________________________________
PRINTED NAME:_____________________________________________________________________
POSITION WITH PRIMARY CONTRACTOR: _____________________________________________
1 If employer does not have an FEIN, please provide social security number.
W. Va. Code R. § 85-10-9