Workers’ Compensation Insurance Affidavit
Workers’ Compensation Information Form
THIS FORM REQUIRES A NOTARY SEAL
AFFIDAVIT OF EXEMPTION
The undersigned affirms that he/she is not required to provide workers’ compensation insurance under the provisions of Pennsylvania’s Workers’ Compensation Law for one of the following reasons as indicated:
____ Property owner is performing own work. If property owner does hire a contractor to perform any work pursuant to the building permit, contractor must provide proof of workers’ compensation insurance to the municipality. Building owner assumes liability for contractor compliance with this requirement.
____ Contractor has no employees. Contractor prohibited by law from employing any individual to perform work pursuant to this building permit unless contractor provides proof of insurance to the municipality.
____ Religious exemption under Workers’ Compensation Law. All employees of contractor are exempt from workers’ compensation insurance. (Attach copies of religious exemption letters for all employees).
____ Use this form when applicable to part “C” on the workers’ compensation form.
Signature of Applicant: ___________________________________
County of: ___________________________________
Municipality of: ___________________________________
Subscribed, sworn to and acknowledged before me by the above
_________________________________ This ______ Day of _______________, 20_____.
(Printed name of applicant)
SEAL
_________________________________________ _____________________________
Signature of Notary Public
MUST BE NOTARIZED
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- workers compensation insurance affidavit
- workers and physician s report for workers compensation
- model sop federal employees compensation act feca for
- the three parts of workers compensation
- worker s and health care provider s report for workers
- workplace posting requirements michigan
- the official website of the state of indiana
- workers compensation
- your workers compensation benefits
Related searches
- ny workers compensation law
- workers compensation new york website
- new york workers compensation board
- workers compensation ny rules
- nys workers compensation board
- workers compensation new york guidelines
- workers compensation by state compar
- workers compensation laws
- york insurance workers compensation claims
- workers compensation insurance board california
- florida workers compensation insurance requirements
- workers compensation insurance colorado