Fillable Affidavit of Exemption from Kentucky Workers Compensation Act (City of JEffersontown)

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Affidavit of Exemption from Kentucky Workers Compensation Act (City of JEffersontown)

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City of Jeffersontown – Affidavit of Exemption From the KY Workers’ Compensation Act (Individual) 20190115 \Page 1 of 1
City of Jeffersontown
Department of Permitting and Enforcement
10416 Watterson Trail
Jeffersontown, KY 40299
Phone: (502) 267-8333 Fax: (502) 267-0547
jeffersontownky.gov
Affidavit of Exemption from Kentucky Workers’ Compensation Act
(Individual)
(Please Print)
Applicant, pursuant to KRS 342.610(5), hereby declares exemption from the requirement to obtain workers’
compensation insurance coverage as set forth in KRS 342.340. In support of this claim to exemption, Applicant
states that the following facts are true and correct:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Full name of Applicant_______________________________________________________________________
Home address _______________________________________________ Phone No. _____________________
FEIN or SSN _______________________
The foregoing is true and correct as I verily believe and swear.
__________________________________________
Applicant/or authorized agent
State of Kentucky Labor Cabinet
County of _______________________
The foregoing Affidavit of Exemption was acknowledged and sworn to before me by
_____________________________ this ______ day of _______________, 20_____.
__________________________________________
NOTARY PUBLIC
KENTUCKY STATE AT LARGE
MY COMMISSION EXPIRES_______________, 20_______.
Instructions
This original Affidavit is to be immediately filed by the local building permit office with the Kentucky Department of Workers’
Claims, Division of Security & Compliance, 657 Chamberlin Ave., Frankfort, KY 40601 (1-800-554-8601).
A copy of this Affidavit is to be kept on file with the local office, which issues the building permit.
Notice of Affiant: Fraudulent execution of this form constitutes a criminal offense (KRS 523.030), under the laws of the
Commonwealth.
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Affidavit of Exemption from Kentucky Workers Compensation Act (City of JEffersontown)

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Completed 30 June 2021

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