►Workers’ Compensation Insurance Coverage Information◄
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.
Certificate attached
Name of Workers’ Compensation Insurer: ____________________________
Workers’ Compensation Insurance Policy No. _____________________
Certificate attached
Policy Expiration Date: ___________________________
C. Exemption – MUST BE NOTORIZED
Complete Section C if the applicant is a contractor claiming exemption from providing workers’
compensation insurance.
The undersigned swears or affirms that he/she is not required to provide workers’ compensation
insurance under the provisions of Pennsylvania’s Workers’ Compensation Law for one of the
following reasons, as indicated:
Contractor with no employees. Contractor prohibited by law from employing any
individual to perform work pursuant to this building permit unless contractor
provides proof of insurance to the township.
Homeowner who elects to do all work without contracting or hiring others to assist.
Religious exemption under the Workers’ Compensation Law.
Signature of Applicant: _________________________________ Print Name: _____________________________
Address: ____________________________________________________________ Date: ____________________
Commonwealth of Pennsylvania, County of ___________________
On this, the ________ day of ________________, 20____ before me __________________________,
(Notary)
the undersigned personally appeared ________________________________, known to me (or satisfactorily proven)
(Signatory)
to be the person whose name subscribed to the within instrument, and acknowledged that he/she executed the same
for the purpose herein contained.
In Witness whereof, I hereunto set my hand and official seal.
________________________________
Notary Public
