Coachella, CA · Riverside County
Workers’ Compensation Declaration
A declaration for businesses to report workers’ compensation coverage or state that they will not employ anyone in a way that triggers coverage requirements.
What this form is
The City of Coachella Workers’ Compensation Declaration is used for business activities for which a city license is issued. The signer selects a declaration about self-insurance, workers’ compensation insurance, or not employing anyone in a way that triggers coverage requirements. Depending on the selection, the form asks for the insurance carrier and policy number, as well as the signer’s name, address, date, and signature.
Who needs it
A person conducting business activities for which a Coachella license is issued uses this form to make a workers’ compensation declaration.
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 declaration is signed without a notary; the signer makes one of the listed declarations and signs and dates the form.
How to submit this form
- 1
Download The Form
Download the Workers’ Compensation Declaration PDF.
- 2
Complete The Declaration
Select the applicable declaration and provide the requested information, including the carrier and policy number if applicable.
- 3
Sign And Date
Enter the signer’s name and address, then sign and date the declaration.
- 4
Submit To The City
Submit the 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 Workers’ Compensation Declaration?
- No. The document has no notary block; the signer makes a listed declaration and signs and dates the form.
- 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.
- What does the Workers’ Compensation Declaration ask for?
- The signer selects a declaration about self-insurance, insurance coverage, or not employing anyone in a way that triggers coverage requirements. The form also requests the signer’s name, address, date, and signature.
- When is this declaration used?
- The form refers to business activities for which a city license is issued and asks the signer to declare their workers’ compensation status for those activities.