Poway, CA · San Diego County
Worker’s Compensation Insurance Exemption Request
Poway businesses use this request to provide business details and certify their workers’ compensation exemption status for work or services connected with the city.
What this form is
This form lets a business request a workers’ compensation insurance exemption and provide its contact information, business address, work description, and legal form. The business designee initials statements about coverage, employment-related requirements, and indemnification, then certifies the information under penalty of perjury and signs and dates the request. The form also includes a signature section for a City of Poway designee.
Who needs it
A business seeking a workers’ compensation insurance exemption for work or services connected with the City of Poway should complete this request.
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 request is signed without a notary; the business designee certifies the information under penalty of perjury and signs and dates it.
How to submit this form
- 1
Download the Request
Download the Worker’s Compensation Insurance Exemption Request PDF.
- 2
Complete the Business Details
Enter the business name and contact information, address, work description, and legal form.
- 3
Review and Sign
Initial the acknowledgment statements, complete the certification, and sign and date the form.
- 4
Submit to the City
Submit it to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- What information does the exemption request ask for?
- It asks for the business name and contact information, address, work description, whether work will be done on City premises, legal form, initialed acknowledgments, and signatures.
- Do I need a notary for the Worker’s Compensation Insurance Exemption Request?
- No. The request is signed without a notary; the business designee certifies the information under penalty of perjury and signs and dates it.
- How do I submit the Worker’s Compensation Insurance Exemption Request?
- Submit it to the city department named on the form; check the city website for current contact details.
Need something notarized?
This Worker’s Compensation Insurance Exemption Request doesn’t need a notary — but if you have another Poway form that does, a commissioned online notary can help.