What information does the certificate ask for?

The certificate asks for the date, signature, and company name. It also warns that hiring employees later may trigger workers' compensation requirements.

Do I need a notary for the workers' compensation exemption certificate?

No. This certificate is signed and dated without a notary, and it lists no notarized attachment or sworn related step.

Suisun City, CA · Solano County

No notary required

Certificate of Exemption From Workers' Compensation Insurance

This certificate is for people seeking a city license or permit who certify they will not employ anyone in a way that makes them subject to workers' compensation laws.

What this form is

The certificate records a statement that, while performing work for which a city license or permit is issued, the signer will not employ anyone in a way that makes them subject to workers' compensation laws. It asks for the date, signature, and company name. The form warns that hiring employees later may trigger workers' compensation requirements and revoke the business license if those requirements are not met.

Who needs it

A person seeking a city license or permit who certifies they will not employ anyone in a manner that makes them subject to workers' compensation laws needs this certificate.

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 certificate is signed and dated without a notary; it lists no notarized attachment or sworn related step.

How to submit this form

1
Download The Certificate
Download the workers' compensation exemption certificate PDF.
2
Complete The Certificate
Enter the date, sign the certificate, and provide the company name.
3
Gather Attachments
The document does not list any attachments.
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 does the workers' compensation exemption certificate do?: It records the signer's certification that they will not employ anyone in a way that makes them subject to workers' compensation laws while performing work for the license or permit.
What information does the certificate ask for?: The certificate asks for the date, signature, and company name. It also warns that hiring employees later may trigger workers' compensation requirements.
Do I need a notary for the workers' compensation exemption certificate?: No. This certificate is signed and dated without a notary, and it lists no notarized attachment or sworn related step.
How do I submit the workers' compensation exemption certificate?: Submit it to the city department named on the form; check the city website for current contact details.

Need something notarized?

This Certificate of Exemption From Workers' Compensation Insurance doesn’t need a notary — but if you have another Suisun City form that does, a commissioned online notary can help.