Windsor, CA · Sonoma County
Workers’ Compensation Declaration
People seeking a Town permit or agreement use this declaration to affirm whether their work will make them subject to workers’ compensation laws.
What this form is
This declaration records a signer’s statement about whether work covered by a Town permit or agreement will make them subject to California workers’ compensation laws. The signer affirms under penalty of perjury that they will comply if those laws apply. The form also warns about consequences for failing to secure coverage and provides spaces for a signature and date.
Who needs it
A person performing work for which the Town issues a permit or agreement may need to complete and sign this 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 affirms under penalty of perjury and signs and dates the form.
How to submit this form
- 1
Download The Declaration
Download the Workers’ Compensation Declaration PDF.
- 2
Complete The Form
Read the affirmation and warning, then provide your signature and date.
- 3
Check For Attachments
This declaration does not identify any attachments.
- 4
Submit To The Town
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 do?
- It records the signer’s affirmation about workers’ compensation coverage for work connected to a Town permit or agreement.
- Who signs this declaration?
- The person performing work for which a Town permit or agreement is issued signs and dates the declaration.
- Do I need a notary for the Workers’ Compensation Declaration?
- No. This declaration is signed without a notary; the signer affirms under penalty of perjury 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.
Need something notarized?
This Workers’ Compensation Declaration doesn’t need a notary — but if you have another Windsor form that does, a commissioned online notary can help.