Dana Point, CA · Orange County
Workman's Compensation Declaration
This declaration is completed by a permit applicant or authorized agent to state how workers' compensation requirements will be met for the permitted work.
What this form is
The declaration records whether the applicant maintains workers' compensation coverage, has consent to self-insure, or will not employ anyone in a way that requires coverage. It also requests insurance details when applicable, the contractor license number, permit number, project address, and applicant or agent information. The signer affirms the statements under penalty of perjury and agrees to comply with applicable construction laws.
Who needs it
A permit applicant or authorized agent completing the declaration for work covered by a city permit needs this form.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
No notary is required; the applicant or authorized agent signs and dates the declaration, which includes an affirmation under penalty of perjury.
How to submit this form
- 1
Download The Declaration
Download the Workman's Compensation Declaration PDF.
- 2
Complete The Form
Select the applicable workers' compensation declaration and fill in the requested insurance, license, permit, project, and applicant details.
- 3
Sign And Date
The applicant or authorized agent signs and dates the declaration under penalty of perjury.
- 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
- Do I need a notary for the Workman's Compensation Declaration?
- No. The document has no notary block; the applicant or authorized agent signs and dates it, affirming the declaration under penalty of perjury.
- Who completes this declaration?
- The permit applicant or an authorized agent completes and signs it. The form asks for workers' compensation information, a contractor license number, permit number, and project address.
- What workers' compensation information does the form request?
- It provides declarations for self-insurance, workers' compensation coverage, or not employing anyone subject to the workers' compensation laws. If coverage applies, it asks for the insurer, policy number, and expiration.
- How do I submit the Workman's Compensation Declaration?
- Submit it to the city department named on the form; check the city website for current contact details.