A. The applicant is:
A contractor within the meaning of the pennsylvania workers compensation law.
If the answer is “yes”, complete sections B and C below, as appropriate.
B. Insurance information:
Name of applicant: ___________________________________________________
Federal or state employer identiﬁcation no: ______________________________
Applicant is a qualiﬁed self-insurer for workers compensation.
Name of workers compensation insurer: _________________________________
Workers compensation insurance policy no.# _____________________________
Policy expiration date: ________________________________________________
Complete Section C if the applicant is a contractor claiming exemption from
providing workers compensation insurance.
The undersigned swears or afﬁrms that (s)he is not required to provide workers compensation
insurance under the provisions of pennsylvania workers compensation law for one of the
following reasons, as indicated:
Contractor with no employees. Contractor prohibited by law form employing any individual to
perform work pursuant to this building permit unless contractor provides proof of insurance
Religious exemption under the workers compensation law.
Subscribed and sworn to before me this ____________ Day of _______ 20 ____
Signature of applicant _________________________________________________
County __________________________________________ Municipality ________
Signature and seal of notary public
Commission expires: _______________
insurance coverage information
BOARD O F SUPERV ISORS • 116 W ilson Hill R oad • Dingmans Ferr y, PA 1 8328
Phone: 570.828-2347 • Fax: 570-828-8705 • Ema il:email@example.com