Waterbury, CT · New Haven County
Proof of Workers’ Compensation Coverage
This form documents workers’ compensation coverage or an owner’s or sole proprietor’s promise to require coverage when applying for a building permit.
- 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
Use this Connecticut Workers’ Compensation Commission form when applying for a building permit as a property owner or sole proprietor who will act as the general contractor or principal employer. The applicant checks one option to state whether they will submit proof of coverage for employees or will require proof from contractors, subcontractors, and other workers. If choosing the latter option, the applicant completes and signs the affidavit before a notary public or Commissioner of the Superior Court.
Who needs it
A property owner or sole proprietor applying for a Waterbury building permit and acting as the project’s general contractor or principal employer may need this form.
Why it needs a notary
The affidavit has a subscribed-and-sworn jurat; the owner or sole proprietor choosing that option signs it before a notary public or Commissioner of the Superior Court.
How to get this notarized
- 1
Download the Form
Download the Proof of Workers’ Compensation Coverage form for your building permit application.
- 2
Complete the Form
Enter the applicant and property details, check one option, and complete the affidavit if applicable.
- 3
Book an Online Notary
Schedule a remote session with a commissioned online notary for the affidavit.
- 4
Sign on Video
Sign the affidavit during the notary’s video session and complete the notarization.
- 5
Submit to the City
Submit the completed form with your building permit application according to Waterbury’s instructions.
Preview the form
The blank PDF straight from Waterbury. 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 the affidavit notarized online?
- Complete the form, then book a session with a commissioned online notary. Sign the affidavit during the video session and submit the notarized form with your building permit application.
- Do I need to notarize this form?
- The form directs you to sign the affidavit before a notary public or Commissioner of the Superior Court if you choose the option stating that you will require workers’ compensation proof from workers.
- Can I use a remote online notary for this affidavit?
- Connecticut authorizes remote online notarization for its own notaries under Public Act 23-28, codified at Conn. Gen. Stat. §3-95b; Conn. Gen. Stat. §1-57 recognizes certain out-of-state notarial acts. Check acceptance with Waterbury before booking.
- Where do I submit the completed form?
- The form is for use when applying for a building permit. Follow Waterbury’s submission instructions, and confirm with the town clerk if unsure.
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.