Work-Comp-Insurance-Affidavit.doc

Work-Comp-Insurance-Affidavit.doc - Workers Compensation...

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Workers’ Compensation Information Form THIS FORM REQUIRES A NOTARY SEAL AFFIDAVIT OF EXEMPTION The undersigned 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 : ____ Property owner is performing own work. If property owner does hire a contractor to perform any work pursuant to the building permit, contractor must provide proof of workers’ compensation insurance to the municipality. Building owner assumes liability for contractor compliance with this requirement. ____ Contractor has no employees. Contractor prohibited by law from employing any individual to perform work pursuant to this building permit unless contractor provides proof of
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