Middlebury, CT · New Haven County
Workers’ Compensation Coverage Proof
This form documents workers’ compensation coverage exclusion for a general contractor or principal employer applying for a building permit for a construction project in Middlebury.
- 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 applicable certificate filed with the Workers’ Compensation Commission, then swears to require proof of workers’ compensation insurance from each contractor, subcontractor, or other worker before work begins. The affidavit refers to Section 31-286b of the Workers’ Compensation Act.
Who needs it
A general contractor or principal employer applying for a building permit who has properly excluded themselves from workers’ compensation coverage may need to complete this form.
Why it needs a notary
The form has a jurat for the affidavit: the general contractor or principal employer signs and swears to its statements before a notary public or Commissioner of the Superior Court.
How to get this notarized
- 1
Download the Form
Get the Workers’ Compensation Coverage Proof form from the Town of Middlebury.
- 2
Complete the Form
Print or type the applicant and business information, select the applicable role and certificate, and review the affidavit.
- 3
Book an Online Notary
Schedule a remote session with a commissioned online notary.
- 4
Sign on Video
Join the video session and sign and swear to the affidavit before the notary.
- 5
Submit to the Town
Submit the completed notarized form as part of your Middlebury building permit application.
Preview the form
The blank PDF straight from Middlebury. 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 get this affidavit notarized online?
- Complete the form, then meet with a commissioned online notary by video and sign when instructed. Connecticut authorizes remote online notarization for its own notaries under Public Act 23-28, effective October 1, 2023.
- Do I need to notarize this form?
- The affidavit includes a jurat stating it must be subscribed and sworn before a notary public or Commissioner of the Superior Court. The form says the applicant signs the affidavit if applicable.
- Who completes the form?
- It is for a general contractor or principal employer applying for a building permit who has properly excluded themselves from workers’ compensation coverage and filed the applicable certificate with the Workers’ Compensation Commission.
- Where do I submit the completed form?
- The form is for use when applying for a building permit in Middlebury. Check with the town about its submission process and any additional requirements; confirm with the town clerk if unsure.
Other forms in Middlebury
Workers’ Compensation Coverage Proof in other Connecticut cities
Each city publishes its own version of this form. Pick the city where you’re filing.