Fillable Clb-affidavit-of-exemption - AFFIDAVIT OF EXEMPTION

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Clb-affidavit-of-exemption - AFFIDAVIT OF EXEMPTION

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U.S.A. forms for Warren County Kentucky

BROWSE WARREN COUNTY KENTUCKY (KY) FORMS

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AFFIDAVIT OF EXEMPTION
FROM THE
WORKERS’ COMPENSATION ACT
The Affiant, ________________________________________, being duly sworn states that
_______________________________________________, is exempt from the provisions of the
NAME OF BUSINESS
Kentucky Workers’ Compensation Act, KRS Chapter 342. Affiant states that the form of
Business is:
Individual Proprietorship
Corporation
Partnership, the names of the partners are ______________________________
______________________________________________________,
Affiant states that _________________________________________________________, has
NAME OF THE BUSINESS
no employees. Affiant states that __________________________________________________
NAME OF THE BUSINESS
will employee no subcontractors with employees without first obtaining a policy of workers’
compensation insurance. The Affiant affirms that should this status change prior to renewal of the
contractors license, that the Affiant will advise the Bowling Green-Warren County Contractors Licensing
Board.
The Affiant further states that any contractors, subcontractors, or employees shall be in
Compliance with Kentucky requirements for Workers’ Compensation insurance according to KRS Chapter
342.
This the ________ day of _____________________
, 20
 .
_
___
___
______________________________________
AFFIANT
STATE OF KENTUCKY
COUNTY OF WARREN
Subscribed and sworn to before me by ________________________________________
This ________ day of ___________________________
, 20
 .
_
___
___
______________________________
NOTARY PUBLIC
My Commission Expires: ________________
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Clb-affidavit-of-exemption - AFFIDAVIT OF EXEMPTION

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Completed 1 November 2019

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