- Employee's Notice of Claim and/or Request for Hearing - South Carolina
- Contractor's Certificate of Workers' Compensation Insurance - Virginia
- Workers Compensation Exemption Form - Florida
- Application for Ohio Workers' Compensation Coverage
- Workers' Compensation Information - Pennsylvania
- Workers' Compensation Form - Massachusetts
Fillable Printable Workers' Compensation Information - Pennsylvania
Fillable Printable Workers' Compensation Information - Pennsylvania
Workers' Compensation Information - Pennsylvania
North Whitehall Township Zoning Office
READ DIRECTIONS CAREFULLY, Before completing this form.
I. The contractor for this building permit, in compliance with ACT 44 of 1993, hereby submits (please check one):
DIRECTIONS
A building permit will not be issued by North Whitehall Township until this form is completed properly.
: Please complete all sections. All blank spaces must be completed with the requested information
and boxes must be checked as they pertain to your status with the Pennsylvania Workman’s Compensation
Insurance Law. If you are claiming an exemption, this form must be signed in the presence of a Notary Public.
NOTE: If an exemption is claimed, this form will be maintained in North Whitehall Township’s records for 1 (one) year.
It is the responsibility of the contractor to renew this permit annually. If the contractor attaches a Certificate of
Insurance, the contractor must notify their insurance company that North Whitehall Township is to be named as a
policy certificate holder.
NOTE: If an exemption is claimed, this form will be maintained in North Whitehall Township’s records for 1 (one) year.
It is the responsibility of the contractor to renew this permit annually. If the contractor attaches a Certificate of
Insurance, the contractor must notify their insurance company that North Whitehall Township is to be named as a
policy certificate holder.
Certificate of Insurance (please Attach)
Certificate of Self-Insurance (please Attach)
Affidavit of Exemption (must be signed in front of a notary public)
II. Name of Contractor
Title of Company
Address
Address
City
City
State
State
Zip Code
Zip Code
Policy No.
Coverage Period Ends
IF APPLICANT CLAIMS EXEMPTION PLEASE COMPLETE BOTH SIDES OF THIS FORM.
Contractor/Policyholder’s federal or state Employer Identification Number (EIN)
III. If a Certificate of Insurance or Self-Insurance has been submitted, please complete the following:
Name of Insurer or Self-Insurer
Phone No.
PENNSYLVANIA WORKERS COMPENSATION
INSURANCE COVERAGE INFORMATION FORM
3256 Levans Road, Coplay (Ironton) PA 18037
Hours: 7:30 a.m. - 4:00 p.m., Mon. - Fri.
Phone (610) 799-3411 Fax (610) 799-9629
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DATE REC’D
Basis for Exemption (please check one):
The Contractor for this building permit is a sole proprietorship without employees
The Contractor is a corporation, and the only employees working on the project are and have
been qualified as “Executive Employees” under section 104 of the Workers’ Compensation Act.
Please Explain:
All of the contractor’s employees on the project are exempt on religious grounds under
Section 304.2 of the Worker’s Compensation Act.
Please Explain:
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 building permit is to be named a policy
certificate holder.
3. Any subcontractors working on this project will be required to carry their own workers’ 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 a building permit will subject the contractor
Violation of the Workers’ Compensation Act or the terms of a building permit will subject the contractor
or policyholder to a STOP WORK ORDER and other fines and penalties as provided by law.or policyholder to a STOP WORK ORDER and other fines and penalties as provided by law.
Other. Please explain:
Subscribed and sworn to before me this
(Signature of Notary Public)
My Commission expires:
Signature
Date
Name (Please Print)
Title
Name of Company
My signature on behalf of or as the contractor for this
building permit constitutes my verification that the
statements contained herein are true, and that I am subject
to penalties as prescribed in 18 Pa. C.S.A. §4904 relating to
unsworn falsification to North Whitehall Township authorities.
day of
IF AN EXEMPTION IS BEING CLAIMED, PLEASE COMPLETE THE FOLLOWING AND
SIGN IN THE PRESENCE OF A NOTARY PUBLIC:
IF AN EXEMPTION IS BEING CLAIMED, PLEASE COMPLETE THE FOLLOWING AND
SIGN IN THE PRESENCE OF A NOTARY PUBLIC:
Please be aware of the following requirements of the Pennsylvania Workers’ Compensation Act:
