Middlebury, CT · New Haven County
Proof of Workers’ Compensation Coverage
This form documents workers’ compensation coverage or an affidavit promising to require coverage, for a property owner or sole proprietor applying for a building permit as general contractor or principal employer.
- 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
When applying for a building permit, a property owner or sole proprietor who will act as general contractor or principal employer uses this form to identify the applicant and property and select how coverage will be provided. The applicant can submit proof of coverage for employees or, if they will require proof from each contractor, subcontractor, or other worker, complete and swear to the affidavit. The affidavit refers to Section 31-286b of the Workers’ Compensation Act.
Who needs it
A property owner or sole proprietor applying for a building permit who will act as general contractor or principal employer must complete the applicable section.
Why it needs a notary
The affidavit has a subscribed-and-sworn jurat, and the owner or sole proprietor signs it before a notary public or Commissioner of the Superior Court.
How to get this notarized
- 1
Download the Form
Get Part 7B from the Town of Middlebury and review the coverage options.
- 2
Fill Out the Form
Enter the applicant and property details, then select the option that applies to your coverage plan.
- 3
Book an Online Notary
If completing the affidavit, schedule a remote session with a commissioned online notary.
- 4
- 5
Submit to the Town
Include the completed form with your building permit application as directed by Middlebury.
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 complete the affidavit?
- Select the affidavit option, fill in the requested business and applicant details, and sign the affidavit before a notary public or Commissioner of the Superior Court.
- Do I need to notarize this form?
- The affidavit section must be sworn and signed before a notary public or Commissioner of the Superior Court. The form does not call for notarization of the other coverage options.
- Can I use a commissioned online notary?
- Connecticut authorizes remote online notarization by its own commissioned online notaries under Public Act 23-28, codified at Conn. Gen. Stat. §3-95b, effective October 1, 2023. Conn. Gen. Stat. §1-57 recognizes qualifying notarial acts performed outside Connecticut.
- Where do I submit the completed form?
- Submit it with your building permit application as directed by the town. Confirm with the town clerk if unsure.
Other forms in Middlebury
Proof of Workers’ Compensation Coverage in other New Haven County cities
Each city publishes its own version of this form. Pick the city where you’re filing.