El Cerrito, CA · Contra Costa County
Workers’ Compensation Declaration
Contractors complete this declaration for work covered by a city permit, stating how they meet workers’ compensation requirements or that they will not employ workers.
What this form is
This form records a contractor’s workers’ compensation declaration for work covered by a city permit. The signer selects whether they maintain self-insurance, carry workers’ compensation insurance, or will not employ anyone in a way that makes them subject to those laws. It also asks for insurance carrier and policy details when applicable, plus contractor and business license information.
Who needs it
Contractors doing work covered by a city permit complete this declaration and provide their workers’ compensation and business details.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This document is signed without a notary; the signer affirms the declaration under penalty of perjury and signs and dates it.
How to submit this form
- 1
Download The Declaration
Download the Workers’ Compensation Declaration PDF.
- 2
Complete The Form
Select the applicable declaration and fill in the requested contractor, business, and insurance information.
- 3
Gather Insurance Details
If applicable, provide the workers’ compensation insurance carrier and policy number.
- 4
Submit To The City
Submit the completed form to the city department named on it; check the city website for current contact details.
Frequently asked questions
- What is the Workers’ Compensation Declaration for?
- It records a contractor’s workers’ compensation declaration for work covered by a city permit and asks for contractor and business license information.
- Who completes this declaration?
- Contractors doing work covered by a city permit complete the form and select the applicable workers’ compensation declaration.
- Do I need a notary for the Workers’ Compensation Declaration?
- No. The document is signed without a notary, though the signer affirms the declaration under penalty of perjury.
- How do I submit the Workers’ Compensation Declaration?
- Submit it to the city department named on the form; check the city website for current contact details.
Need something notarized?
This Workers’ Compensation Declaration doesn’t need a notary — but if you have another El Cerrito form that does, a commissioned online notary can help.