Roxbury, NY · Delaware County
Affidavit of Exemption to Show Specific Proof of Workers’ Compensation Insurance Coverage
This affidavit lets qualifying homeowners state why they are exempt from showing workers’ compensation coverage when applying for a building permit.
What this form is
The BP-1 affidavit is for owners of one- to four-family, owner-occupied residences who are applying for a building permit and meet one of the listed exemption conditions. It asks the homeowner to select a qualifying condition and provide a signature, date, contact information, printed name, and property address. The form says homeowners paying individuals 40 or more aggregate hours per week must use another coverage or proof option.
Who needs it
A homeowner applying for a building permit for a one- to four-family, owner-occupied residence may use this form if a listed exemption condition applies.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This document has no notary block, and the signer signs and dates it; its text says that once notarized, BP-1 serves as an exemption for workers’ compensation and disability benefits coverage.
How to submit this form
- 1
Download the Affidavit
Download the BP-1 workers’ compensation exemption affidavit.
- 2
Complete the Form
Select the applicable exemption condition and fill in the homeowner, contact, and property information.
- 3
Check the Coverage Conditions
Review the form’s options for homeowners paying individuals less than 40 aggregate hours per week.
- 4
Submit the Affidavit
Submit it to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- What is the workers’ compensation exemption affidavit for?
- It lets qualifying owners of one- to four-family, owner-occupied residences state why they are exempt from showing specific workers’ compensation coverage proof for a building permit.
- Who may use the BP-1 affidavit?
- The form is for a homeowner applying for a building permit for a one- to four-family, owner-occupied residence who meets one of its listed exemption conditions.
- Do I need a notary for the workers’ compensation exemption affidavit?
- No notary block appears on this document; the signer signs and dates it. The text says that once notarized, BP-1 serves as an exemption for workers’ compensation and disability benefits coverage.
- How do I submit the workers’ compensation exemption affidavit?
- Submit it to the city department named on the form; check the city website for current contact details.
Need something notarized?
This Affidavit of Exemption to Show Specific Proof of Workers’ Compensation Insurance Coverage doesn’t need a notary — but if you have another Roxbury form that does, a commissioned online notary can help.