Jeffersontown, KY · Jefferson County
Workers’ Compensation Exemption Affidavit (Individual)
This affidavit lets an individual applicant declare exemption from workers’ compensation insurance requirements and is filed with Jeffersontown’s local building permit office.
- 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
An individual applicant uses this form to declare exemption from workers’ compensation insurance requirements and state the facts supporting that claim. For the building permit process, the instructions direct the local building permit office to file the original with the Kentucky Department of Workers’ Claims and keep a copy on file. The form cites KRS 342.610(5) and KRS 342.340.
Who needs it
An individual applicant seeking an exemption from workers’ compensation insurance requirements in connection with a Jeffersontown building permit may need to submit this affidavit.
How to get this notarized
- 1
Download The Affidavit
Get the individual Affidavit of Exemption from the Jeffersontown form page.
- 2
Fill In The Applicant Details
Print the supporting facts, applicant name, home address, phone number, and FEIN or SSN.
- 3
Book An Online Notary
Arrange a remote appointment with a commissioned online notary before signing.
- 4
Sign During The Video Session
Sign when directed by the notary so the affidavit can be acknowledged and sworn.
- 5
Submit It To The City
Provide the original to the local building permit office for filing and follow its instructions.
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
- How do I submit the completed affidavit?
- The form instructs the local building permit office to file the original with the Kentucky Department of Workers’ Claims and keep a copy on file.
- Do I need to sign this affidavit before a notary?
- Yes. The form says the affidavit is acknowledged and sworn to before a notary, so the applicant or authorized agent should sign before the notary.
- Can I sign this affidavit with an online notary?
- Kentucky law provides for online notarization by a commissioned online notary and recognizes notarial acts by authorized officers from other states. Confirm the city’s acceptance requirements if unsure.
- What should I do if I am unsure where to file it?
- The instructions say to give the original to the local building permit office for filing and to keep a copy there. Confirm with the city or county clerk if unsure.