Hoffman Estates, IL · Cook County
Workers’ Compensation Affidavit
Companies without workers’ compensation coverage use this affidavit to explain why the Illinois Workers’ Compensation Act does not require them to retain coverage.
What this form is
An authorized company agent uses this affidavit to attest that the company does not have workers’ compensation coverage and that the Illinois Workers’ Compensation Act does not require it. The signer must give the reason coverage is not required and provide a signature, date, printed name, title, and full company name. The affidavit expires when the listed Comprehensive General Liability coverage expires, and a new one must be submitted each time a new Certificate of Insurance is required.
Who needs it
An authorized agent of a company without workers’ compensation coverage uses this affidavit when the Illinois Workers’ Compensation Act does not require the company to retain coverage.
How to submit it
The form says a new affidavit must be submitted each time a new Certificate of Insurance is required. Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This affidavit is signed and dated without a notary; the signer provides the reason workers’ compensation coverage is not required.
How to submit this form
- 1
Download The Affidavit
Download the Workers’ Compensation Affidavit for Hoffman Estates.
- 2
Complete The Company Details
Enter the authorized agent’s name, company name, reason coverage is not required, printed name, title, and full company name.
- 3
Sign And Date
The authorized agent signs and dates the affidavit.
- 4
Submit The Affidavit
Submit a new affidavit each time a new Certificate of Insurance is required. Check the city website for current contact details.
Frequently asked questions
- What does the Workers’ Compensation Affidavit state?
- An authorized company agent attests that the company has no workers’ compensation coverage and that the Illinois Workers’ Compensation Act does not require it, then gives the reason.
- Who completes this affidavit?
- An authorized agent of the company completes it, providing the agent’s name, signature, date, title, the full company name, and the reason coverage is not required.
- Do I need a notary for the Workers’ Compensation Affidavit?
- No. The document is signed and dated without a notary; the signer provides the reason workers’ compensation coverage is not required.
- How do I submit the Workers’ Compensation Affidavit?
- The form says a new affidavit must be submitted each time a new Certificate of Insurance is required. Submit it to the city department named on the form; check the city website for current contact details.
Need something notarized?
This Workers’ Compensation Affidavit doesn’t need a notary — but Illinois residents can notarize other documents online with a commissioned online notary.