Workers' Compensation Exemption Form printable pdf download

Workers' Compensation Exemption Form

WORKERS’ COMPENSATION EXEMPTION

Complete the following information if the applicant is a contractor claiming exemption from

providing workers’ compensation insurance.

_____________________________________________________________________________

The undersigned swears or 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:

Contractor with 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 township.

Religious exemption under the Workers’ Compensation Law

VERIFICATION

COMMONWEALTH OF PENNSYLVANIA

SS:

COUNTY OF BUCKS

I, ___________________________________, swear or affirm and verify that the statements

made in the foregoing pleading are true and correct to the best of my knowledge, information,

and belief.

_______________________________

____________________________________

Date

SIGNATURE OF APPLICANT

(To be signed in the presence of a Notary)

Sworn to and Subscribed

Before me this _______Day of

_________________________, 20___

________________________________

NOTARY PUBLIC

Workers' Compensation Exemption Form