Rohnert Park, CA · Sonoma County
Workers’ Compensation Declaration
Contractors complete this declaration to state their workers’ compensation coverage or exemption for work covered by a city-issued permit.
What this form is
This declaration records whether the contractor has workers’ compensation insurance, a certificate of consent to self-insure, or will not employ anyone in a way that makes coverage required. It applies to work for which a permit is issued and asks for coverage details when applicable, contractor license and business information, the jobsite address, and the contractor’s signature.
Who needs it
Contractors performing work for which a permit is issued use this form to declare their workers’ compensation coverage or exemption.
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 text identifies no notarized attachment or related step, so the signer simply signs.
How to submit this form
- 1
Download The Declaration
Download the Workers’ Compensation Declaration PDF.
- 2
Complete The Declaration
Select the applicable coverage or exemption statement and enter the requested contractor, license, business, and jobsite information.
- 3
Gather Coverage Details
Have your insurance carrier and policy number available if the form’s coverage section applies.
- 4
Sign And Submit
Sign the declaration and 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 Declaration ask for?
- It asks the contractor to declare workers’ compensation insurance, self-insurance, or an exemption, and to provide applicable coverage and contractor information.
- Who completes this declaration?
- Contractors performing work for which a permit is issued complete the declaration and provide their contractor and jobsite information.
- Do I need a notary for the Workers’ Compensation Declaration?
- No. The declaration is signed without a notary, and the form identifies no notarized attachment or related step.
- How do I submit the Workers’ Compensation Declaration?
- Submit it to the city department named on the form. The form does not provide submission details, so check the city website for current contact information.
Need something notarized?
This Workers’ Compensation Declaration doesn’t need a notary — but if you have another Rohnert Park form that does, a commissioned online notary can help.