Lee's Summit, MO · Jackson County
Affidavit of Exemption for Workers’ Compensation Insurance
This sworn affidavit lets a construction-industry contractor state why their business is exempt from workers’ compensation insurance when applying for an occupational or business license.
At a glance
- Issued by
- City of Lee's Summit · Lee's Summit, Jackson County, Missouri
- Notarization
- Required: sign this form in front of a notary before filing it.
- Official source
- cityofls.net
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
- 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 form is for construction-industry contractors who do not have proof of workers’ compensation insurance and are applying for an occupational or business license. The contractor identifies the business and selects an exemption basis, such as having no employees as a sole proprietor or partner, or qualifying for a corporate exemption. The form explains that a contractor who does not provide proof of coverage or complete the affidavit may be denied a license.
Who needs it
A construction-industry contractor applying for an occupational or business license without proof of workers’ compensation insurance may need to submit this affidavit.
How to get this notarized
- 1
Download the Form
Get the three-page Workers’ Compensation Exemption Affidavit.
- 2
Fill In the Details
Enter the affiant and business information, select the applicable exemption reason, and review the attached statutory provisions and guidelines.
- 3
Book an Online Notary
Arrange a remote notarization with a commissioned online notary, and wait to sign until your appointment.
- 4
- 5
Submit to the City
Submit the completed affidavit with your occupational or business license application as directed by the city.
Preview the form
The blank PDF straight from Lee's Summit. 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 workers’ compensation exemption affidavit?
- Identify yourself and your business, select the exemption reason that applies, review the attached guidelines, then sign and swear to the affidavit before a commissioned online notary.
- Do I need to notarize this affidavit?
- Yes. The form includes a state-and-county jurat and says the affiant’s statements are sworn before a notary. Do not sign until you are with the notary.
- Can I sign this affidavit with a commissioned online notary?
- Missouri authorizes remote online notarization by its own notaries under RSMo §§486.1100–486.1205. Check that the receiving city accepts your remotely notarized affidavit; confirm with the city or town if unsure.
- Who should use this exemption form?
- The form is for a construction-industry contractor applying for an occupational or business license without proof of workers’ compensation insurance who states that the business qualifies for an exemption.
Other forms in Lee's Summit
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Final Development Plan Application and Ownership Affidavit
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Final Plat Application
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Minor Plat Application and Ownership Affidavit
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Preliminary Development Plan Application
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Rezoning Application and Ownership Affidavit
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Affidavit of Exemption for Workers’ Compensation Insurance in other Missouri cities
Each city publishes its own version of this form. Pick the city where you’re filing.