A. The applicant is:
A contractor within the meaning of the pennsylvania workers compensation law.
Yes No
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.
Certification attached
Name of workers compensation insurer: _________________________________
Workers compensation insurance policy no.# _____________________________
Certification attached
Policy expiration date: ________________________________________________
C. Exemption:
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
to township.
Religious exemption under the workers compensation law.
Subscribed and sworn to before me this ____________ Day of _______ 20 ____
Signature of applicant _________________________________________________
Address _____________________________________________________________
County __________________________________________ Municipality ________
Signature and seal of notary public
Commission expires: _______________
Workers compensation
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