Mar 10

Pennsylvania Workers’ Compensation Insurance Coverage Information Form


Please complete all applicable sections of this form paying special attention to the documentation requirements listed in each section. The building and/or zoning permit that you are requesting will not be issued until this form is completed properly.

1. Are you the homeowner/property owner performing the work (as requested in this application) yourself?

☐ No – go to question #2

☐ Yes – read this exemption statement, sign to indicate your understanding and submit this form with your application “Homeowner swears/affirms that he/she will be performing all work on this project and no outside contractors will be employed on this project.”

Signature: ___________________________________ Date: _____________

2. Are you the homeowner/property owner who has hired a contractor to perform the work (as requested in this application)?

☐ No – go to question #3

☐ Yes – please have your contractor complete Sections A & B

3. Are you the contractor hired by the homeowner/property owner to perform the work as requested in this application)?

☐ Yes – complete Section A & B

☐ No – please explain: _______________________________________________________________

A. Name of Company ___________________________________________

Contact person ___________________________________ Phone # _________________________

Address of company ________________________________________________________________

Federal or State Employee Identification # ________________________

Please select one of the following options:

☐ Applicant is a qualified self-insurer for workers’ compensation

Please attach a copy of the insurance certificate listing the municipality in which the work will be performed as a certificate holder

☐ Applicant carries workers’ compensation coverage with an insurance company

Please attach a copy of the insurance certificate listing the municipality in which the work will be performed as a certificate holder

☐ Applicant is exempt from providing workers’ compensation insurance because:

☐ The contractor is a sole proprietorship without employees (The contractor is prohibited by law from employing any individual to perform work pursuant to this building permit unless contractor provides proof of insurance to the municipality.)

☐ All of the contractor’s employees on the project claim an exemption based on religious grounds as defined in Section 304.2 of the Workers’ Compensation Act.

Note: If you are requesting an exemption from the Workers’ Compensation Act requirements, you must sign in Section B in front of a notary public.

Will you be using any subcontractor(s) on this project? ☐ NoYes  (if yes, all subcontractors must present proof of insurance as required under the Pennsylvania Workers’ Compensation Act.)

B. My signature as the contractor indicates my understanding of the requirements to provide proof of Workers’ Compensation insurance as needed and verifies that all statements made above are true. I understand that if I am a contractor requesting an exemption under the Workers’ Compensation Act that I must sign this form in front of a notary public.

Signature _____________________________________ Date ____________

Address ___________________________________________________________________________


County _________             Municipality of _______________________

My commission expires:                                                   Subscribed and sworn to before me this-

________ day of _____________ 20___.

SEAL                                                                                          _________________________________

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