Salisbury, CT · Litchfield County
Workers’ Compensation Coverage Affidavit
This form documents workers’ compensation coverage exclusion for a general contractor or principal employer applying for a building permit for work at a property in Salisbury.
- licensed online notary
- ~15 min average
- Notarized PDF emailed
What you’ll need
- Government-issued photo ID
- Webcam-enabled device (laptop or phone)
- This form, ready to upload as a PDF
What this form is
A general contractor or principal employer who has properly excluded themselves from workers’ compensation coverage completes this form when applying for a building permit. The applicant identifies their business role and the certificate filed with the Workers’ Compensation Commission, then swears to require proof of workers’ compensation insurance from every contractor, subcontractor, or other worker before they work at the project site.
Who needs it
A building permit applicant who is a general contractor or principal employer and has properly excluded themselves from workers’ compensation coverage needs this form.
Why it needs a notary
The form has an affidavit with a jurat stating it was subscribed and sworn before a notary public or Commissioner of the Superior Court; the general contractor or principal employer signs.
How to get this notarized
- 1
Download the Form
Get Form 7C from the Salisbury town website.
- 2
Complete the Form
Print or type the applicant and property information, select your business role and identify the certificate filed.
- 3
Book an Online Notary
Arrange a remote session with a commissioned online notary.
- 4
Sign on Video
Sign the affidavit during the video session before the notary.
- 5
Submit to the City
Submit the completed form with your building permit application.
Preview the form
The blank PDF straight from Salisbury. Look it over, then upload your filled copy to start the notary session.
You’ll need ID and a webcam.
A licensed online notary will join you on video, verify your government-issued ID, witness your signature, and apply their seal. You’ll receive the notarized PDF by email when the session ends.
Frequently asked questions
- How do I complete the notarized affidavit?
- Complete the applicable role and certificate sections, then sign the affidavit before a notary public or Commissioner of the Superior Court. The affidavit states that you will require proof of workers’ compensation insurance from workers at the project site.
- Do I need to sign the form in front of a notary?
- Yes. The form instructs the general contractor or principal employer to sign the affidavit in the presence of a notary public or Commissioner of the Superior Court.
- Can I use a commissioned online notary for this form?
- Connecticut authorizes its notaries to perform remote online notarizations under Public Act 23-28, effective October 1, 2023. Conn. Gen. Stat. §1-57 recognizes qualifying notarial acts performed outside Connecticut. Confirm acceptance with the town clerk if unsure.
Other forms in Salisbury
Workers’ Compensation Coverage Affidavit in other Litchfield County cities
Each city publishes its own version of this form. Pick the city where you’re filing.