VIRGINIA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
OFFICE OF CHARITABLE AND REGULATORY PROGRAMS
PO Box 526 • Richmond, VA 23218-0526
(804) 786-0321 •
www.vdacs.virginia.gov
ocrpregulatory@vdacs.virginia.gov
Revised 03/2019
REMITTANCE FORM
HOME SERVICE CONTRACT PROVIDERS
Annual Registration Fee
$300
(920-02626)
Late Fees*
(920-02799)
Total Fees Submitted
Check Number
Make check payable to the Treasurer of Virginia
Mail to: VDACS, PO Box 526, Richmond VA 23218-0526
Company Name and Address:
Federal Employer Identification Number:
If you have any questions or need additional information,
please contact us at
ocrpregulatory@vdacs.virginia.gov
or
at 804-786-0321.
PLEASE NOTE: Registration forms that are not properly completed, signed and notarized, will be considered
deficient and registration will be withheld until the filing is complete.
LATE FILING FEES
*Late Fees: Initial registration - Any obligor who fails to register prior to the sale of a home service contract
shall pay a late fee of $100 for each 30 day period, or portion thereof, that the registration is late.
st
*Late Fees: Renewal registration – renewal registrations not postmarked before or on July 1
shall include a
late annual registration fee in the amount of $50 for each 30 day period, or portion thereof, that the annual
renewal filing is late.
This office will strive to have your registration application and required documents reviewed within 30 days
of the receipt of the registration submission. Before contacting us, please allow sufficient time for review
and processing. During higher activity periods, processing time may be longer.
Form 801
Page 1 of 6
Rev. 03/19
VIRGINIA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
OFFICE OF CHARITABLE AND REGULATORY PROGRAMS
PO Box 526 • Richmond, VA 23218-0526
(804) 786-0321 •
www.vdacs.virginia.gov
ocrpregulatory@vdacs.virginia.gov
Revised 03/2019
REMITTANCE FORM
HOME SERVICE CONTRACT PROVIDERS
Annual Registration Fee
$300
(920-02626)
Late Fees*
(920-02799)
Total Fees Submitted
Check Number
Make check payable to the Treasurer of Virginia
Mail to: VDACS, PO Box 526, Richmond VA 23218-0526
Company Name and Address:
Federal Employer Identification Number:
If you have any questions or need additional information,
please contact us at
ocrpregulatory@vdacs.virginia.gov
or
at 804-786-0321.
PLEASE NOTE: Registration forms that are not properly completed, signed and notarized, will be considered
deficient and registration will be withheld until the filing is complete.
LATE FILING FEES
*Late Fees: Initial registration - Any obligor who fails to register prior to the sale of a home service contract
shall pay a late fee of $100 for each 30 day period, or portion thereof, that the registration is late.
st
*Late Fees: Renewal registration – renewal registrations not postmarked before or on July 1
shall include a
late annual registration fee in the amount of $50 for each 30 day period, or portion thereof, that the annual
renewal filing is late.
This office will strive to have your registration application and required documents reviewed within 30 days
of the receipt of the registration submission. Before contacting us, please allow sufficient time for review
and processing. During higher activity periods, processing time may be longer.
Form 801
Page 1 of 6
Rev. 03/19
VIRGINIA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
OFFICE OF CHARITABLE & REGULATORY PROGRAMS
HOME SERVICE CONTRACT PROVIDER REGISTRATION APPLICATION
GENERAL INSTRUCTIONS
A.
Use this application to register as a Home Service Contract Provider.
B.
Complete this application in its entirety. If a response field or question is not applicable, please indicate
"N/A".
C.
Please print legibly in ink or type all responses.
D.
If necessary, please attach relevant documents and/or explanation sheets. In doing so, please
identify the corresponding question on each document/sheet.
E.
Ensure the application is dated and signed by an authorized individual of the applicant.
F.
Enclose a $300 application fee payable to: Treasurer of Virginia.
G.
If applicable, any provider that fails to register prior to the sale of a home service contract shall pay a
late filing fee of $100 for each 30-day period, or portion thereof, that the registration is late.
H.
Complete either section 5 or section 6 of the application. Applicant is not required to complete both
sections.
I.
Mail completed registration form and all required documents/attachments to:
Virginia Department of Agriculture and Consumer Services
PO Box 526
Richmond VA 23218-0526
SECTION 1
APPLICANT INFORMATION
Full Corporate Name of Entity or Full Legal Name If Sole Proprietorship
Doing Business As/Trading As Name
Physical Address
City
State
Zip Code
Country
Telephone Number, including area code
Fax Number, including area code
Website Address
Mailing Address (if different from physical address)
City
State
Zip Code
Country
SECTION 2
PRIMARY CONTACT INFORMATION
Primary Contact Person
Title
Physical Address
City
State
Zip Code
Country
Telephone Number, including area code
Email Address
Form 801
Page 2 of 6
Rev. 03/19
SECTION 3
FEDERAL & STATE REGISTRATION INFORMATION
3-1.
Business Type
Corporation
General Partnership
Limited Liability Company
(check one)
Sole Proprietorship
Limited Partnership
Holding Company
Other (please specify)
3-2.
Federal Employer Identification Number or Social Security Number (if a sole proprietorship):
3-3.
Is the applicant in ‘good standing’ with the state of its incorporation
Yes - attachment included
or organization? If yes, please attach a copy of the certificate of
No -explanation sheet included
good standing. If no, please attach an explanation sheet detailing the
N/A
reason.
3-4.
If the applicant is not incorporated or organized under Virginia law, is
Yes
it registered with the Virginia State Corporation Commission
No
indicating its qualification to do business in Virginia?
3-5.
If the applicant is not incorporated, organized or registered under
Virginia law, please attach an explanation sheet identifying the law
Explanation sheet included
under which it is organized and stating whether it is qualified to do
N/A
business in Virginia.
3-6.
Identify the applicant’s registered agent in Virginia:
Name of Registered Agent
Mailing Address
City
State
Zip Code
Telephone Number, including area code
Fax Number, including area code
3-7.
Is the applicant in ‘good standing’ with the Virginia Department of
Yes
Taxation with any and all tax obligations owed to Virginia?
No
Please provide all aliases/business names used by the applicant to conduct business, provide approximate time periods
during which the aliases/business names were used by the applicant and if applicable, the state of incorporation.
3-8.
Name
Time Period (month, year)
State of Incorporation
Name
Time Period (month, year)
State of Incorporation
Name
Time Period (month, year)
State of Incorporation
Please provide a list of the owners of the applicant and the nature of
3-9.
Attachment included
the applicant’s business.
SECTION 4
FINANCIAL INFORMATION
4-1.
Attach a copy of the applicant’s audited financial statement. Please
Attachment included
note, audited financials are required, and only audited financial
statements will be accepted, pursuant to the requirements of the
VHSCA.
Form 801
Page 3 of 6
Rev. 03/19
SECTION 5
BOND, LETTER OF CREDIT & FUNDED RESERVE INFORMATION
Complete this section if the applicant is providing information on its bond or letter of credit and its funded reserve. Completion of
section 4 is not required if applicant completes section 5.
5-1.
Is the applicant’s bond with a corporate surety from a company
authorized to transact business in the Commonwealth; or a letter
Yes
of credit from a bank insured by the Federal Deposit Insurance
No
Corporation (FDIC)?
5-2.
What is the total dollar amount of unexpired home service contracts?
$
5-3.
Is the total amount of unexpired home service contracts
consistent with the amount of the bond or letter of credit
required in the chart below?
Total Amount of Unexpired
Required Amount of Bond
Yes
or Home Service Contracts
Letter of Credit
No
$50,000 or less
$10,000
$50,001 to 300,000
$40,000
$300,001 to $750,000
$65,000
$750,001 or more
$90,000
Yes - attachment included
5-4.
Is the ORIGINAL, signed bond or letter of credit attached to the
No
application and in favor of the Commonwealth of Virginia?
5-5.
Does the applicant maintain a funded reserve account for its
Yes
obligations under it home service contracts issued and outstanding
No
in Virginia?
5-6.
Is the funded reserve, as maintained by the applicant, not less than
40% of the gross consideration received, less claims paid, on the sale
Yes
of the home service contract for all in-force home service contracts
No
sold in Virginia?
SECTION 6
CONTRACTUAL LIABILITY INSURANCE POLICY (CLIP) INFORMATION
Complete this section if the applicant is providing information on its contractual liability insurance policy.
**Completion of section 6 is not required if applicant completes section 5.
6-1.
Is the CLIP issued by an insurer authorized to transact business
Yes
in Virginia?
No
6-2.
Does the CLIP cover 100% of the provider’s home service contract
Yes
liabilities, including the administration of claims and the cost for such
No
administration?
Yes
6-3
Does the CLIP have a cancellation statement indicating that prior to
No
cancellation by either party, a 60-day notice must be provided to the
Commissioner of VDACS?
Attach a copy of the applicant’s CLIP, which covers the home service
6-3.
Attachment included
contracts in effect.
Form 801
Page 4 of 6
Rev. 03/19
SECTION 7
LICENSE, PERMIT OR REGISTRATION INFORMATION
7-1.
Does the applicant possess a home service contract provider
license, permit, or registration issued by a licensing authority in
another state, territory or jurisdiction? If yes, please attach a list
Yes - attachment included
including the type of license, the licensing authority, the license
No
number, and the name and telephone number of the appropriate
contact person at the issuing authority.
7-2.
Has the applicant ever had a home service contract provider
license, permit, or registration denied, limited, restricted, not
renewed, revoked, suspended, or subject to an administrative
Yes - explanation sheet included
proceeding? If yes, please attach an explanation sheet detailing
No
the facts and circumstances concerning the matter, including the
name of the licensing authority, the date of each action taken and
the reason for the action.
7-3.
Did the applicant begin selling home service contracts in
Virginia prior to submitting this application? If yes, please
Yes - explanation sheet included
No
attach an explanation sheet disclosing the date the applicant
began selling home service contracts in Virginia.
DISCLAIMERS AND AFFIDAVITS
By completing this section and affixing my signature, I hereby state that I am authorized to sign this application on behalf of the
applicant, and, to the best of my knowledge, information and belief, there has been no misrepresentation or failure to disclose.
I am aware that later discovery of an omission or misrepresentation made in this application, or made on any statement,
document, or information may be grounds for denial of the applicant's application or revocation of the applicant’s registration, or
subject the applicant or personnel to criminal penalties in the Commonwealth of Virginia.
I agree that I will notify the Office of Charitable and Regulatory Programs (OCRP) of any circumstance that necessitates amending
any response provided in this application.
I agree that I will abide by the laws and regulations governing home service contracts in the Commonwealth of Virginia.
I understand that changes in the total amount of unexpired home service contracts may warrant a change in the amount of the
surety bond or letter of credit on file and, as such, I will promptly submit a Rider/Amendment for the surety bond or LOC to OCRP
in accordance with § 59.1-434.3 of the Code of Virginia.
If a liability insurance policy is on file with OCRP, I understand that I may not cancel this policy or the issuer of the policy may not
cancel this policy without providing a minimum 60 days notice to OCRP of the cancellation. I further understand that if the policy
is cancelled, I must provide a new policy, bond, or letter of credit to OCRP prior to the effective date of the policy cancellation.
Signature
Date
Print Name
Title
Form 801
Page 5 of 6
Rev. 03/19
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