Jeffersontown, KY · Jefferson County
Workers’ Compensation Act Exemption Affidavit (Corporation or Partnership)
This affidavit lets a corporation or partnership claim an exemption from Kentucky workers’ compensation insurance requirements and is completed by the applicant or an authorized agent.
- 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
The applicant states facts supporting an exemption from the requirement to obtain workers’ compensation insurance coverage. The instructions say the local building permit office must immediately file the original with the Kentucky Department of Workers’ Claims, Division of Security & Compliance, and keep a copy on file. The form is for a corporation or partnership seeking the exemption.
Who needs it
A corporation or partnership claiming an exemption from workers’ compensation insurance coverage completes this form through an applicant or authorized agent.
Why it needs a notary
The form includes an acknowledgment and sworn statement before a notary public; the applicant or authorized agent signs on behalf of the corporation or partnership.
How to get this notarized
- 1
Download The Affidavit
Get the one-page affidavit for a corporation or partnership claiming a workers’ compensation exemption.
- 2
Complete The Form
Print clearly and enter the applicant, business, employee, and exemption information requested.
- 3
Book An Online Notary
Schedule a remote session with a commissioned online notary, and have the completed form ready.
- 4
Sign On Video
Follow the notary’s instructions and sign the affidavit during the online session.
- 5
Submit To The City
Ask the local building permit office how to submit the notarized original for filing and provide any required copy.
Preview the form
The blank PDF straight from Jeffersontown. 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
- Who completes this exemption affidavit?
- The applicant, or an authorized agent acting for a corporation or partnership, completes the affidavit and states the facts supporting the exemption claim.
- How do I submit the completed affidavit?
- The instructions say the local building permit office files the original with the Kentucky Department of Workers’ Claims and keeps a copy on file. Contact the office about its submission process.
- Do I need to sign the affidavit in front of a notary?
- Yes. The form says the statement is sworn and acknowledged before a notary public. Wait to sign until your notary gives you instructions.
- Can I use an online notary for this affidavit?
- Kentucky authorizes online notarization by a commissioned online notary. Ask the local building permit office whether it accepts this notarized form; confirm with the city or county clerk if unsure.