Fillable Workers Compensation Insurance Certification

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Workers Compensation Insurance Certification

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U.S.A. forms for Borough of Greencastle

BROWSE BOROUGH OF GREENCASTLE (PA) FORMS

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Addendum to Zoning Permit
I. The applicant for the zoning permit, in compliance with the Workers’
Compensation Reform Act #44 of 1993, hereby submits the following (check
only one):
Certificate of Insurance (please attach) *Complete Sections II & IV
Certificate of Self-Insurance (please attach) *Complete Sections II & IV
Affidavit of Exemption *Complete Sections III & IV
II. If a Certificate of Insurance or Self-Insurance has been submitted, please
complete the Following:
Name of Insurer or Self-Insurer
Address
City
ZIP Code
Policy No.
Coverage Periods Ends
Name of Contractor/Policy Holder
Address
City
ZIP Code
Contractor/Policyholder’s federal or state employer
identification number (EIN):
1. This policy provides coverage for the requirements of the Workers’ Compensation
Act, the Occupational Disease Act, and where applicable, the federal Longshore
and Harbor Workers’ Compensation Act.
2. The Insurer has been notified that the municipality issuing the zoning permit is to
be named a policy certificate holder.
3. Any subcontractors used on this project will be required to carry their own
worker’s compensation coverage.
4. The contractor/policyholder will notify the municipality of any change in status,
cancellation or expiration of workers’ compensation coverage.
5. Violation of the Workers’ Compensation Act or the terms of this permit will subject
the contractor/policyholder to a stop-work order and other fines and penalties as
provided by law.
III. If exemption is being claimed, please complete the following and sign.
Basis for exemption (check only one):
Applicant is an individual who owns property
Contractor/Applicant is a sole proprietorship without employees
Contractor/Applicant is a corporation, and the only employees working on
the project have and are qualified as “Executive Employees” under Section
104 of the Workers’ Compensation Act
All of the contractor/applicant’s employees on the project are exempt on
religious grounds under Section 304.2 if the Workers’ Compensation Act
Please Explain:
Other - Please Explain:
1. Any subcontractors used on this project will be required to carry their own
workers’ compensation coverage.
2. The applicant is not permitted to employ any individual to perform work on this
project pursuant to the permit in violation of the Act.
3. Violation of the Workers’ Compensation Act or the terms of this permit will subject
the applicant to a stop-work order and other fines and penalties provided by law.
IV. My signature on behalf of or as contractor /applicant for this zoning permit
constitutes my verification that the statement contained here are true, and that I
am subject to penalty of 18 Pa. C.S.A §4904 relating to unsworn falsifications to
authorities.
________________________________________ _______________________________________
Signature Title
________________________________________ _______________________________________
Printed Name Name of Company
________________________________________
Phone
Name of Applicant
Address
City
State
ZIP Code
Applicant’s Federal or state employer identification number (EIN):
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Workers Compensation Insurance Certification

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Completed 12 July 2020

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