Russia, NY · Herkimer County
Insurance Form for Building Permit Application
This form lets qualifying homeowners or businesses document workers’ compensation insurance coverage or claim an exemption when applying for a building permit.
What this form is
The document includes an affidavit for owners of qualifying owner-occupied residences and a separate statement for businesses claiming they do not require workers’ compensation or disability benefits coverage. The building permit applicant uses the applicable section to provide insurance information or explain an exemption. Homeowners who pay workers for 40 or more total hours per week must instead provide appropriate coverage proof or have the general contractor provide it.
Who needs it
Building permit applicants who need to provide workers’ compensation coverage proof or document an exemption may use the applicable section of this form.
How to submit it
Submit the completed form to the government entity issuing the building permit. Business owners are instructed to send the completed business application to the nearest Workers’ Compensation Board Enforcement Unit.
About notarization
This document is signed and dated without a notary; if required, the applicant must provide workers’ compensation coverage proof or have the general contractor provide it.
How to submit this form
- 1
Download The Form
Download the building permit insurance form.
- 2
Complete The Applicable Section
Complete the homeowner affidavit or business statement that applies to the applicant.
- 3
Gather Required Coverage Proof
If the form’s conditions require it, obtain workers’ compensation coverage proof or arrange for the general contractor to provide it.
- 4
Submit The Form
Submit the form to the government entity issuing the building permit; business owners are directed to send their application to the nearest Workers’ Compensation Board Enforcement Unit.
Frequently asked questions
- Who uses the building permit insurance form?
- Building permit applicants use the applicable section to document workers’ compensation coverage or an exemption for a qualifying residence or business.
- Do I need a notary for the building permit insurance form?
- No. The form is signed and dated without a notary. Applicants who meet the stated conditions may need to provide coverage proof instead.
- How do I submit the building permit insurance form?
- Submit it to the government entity issuing the building permit. Business owners are directed to send the completed business application to the nearest Workers’ Compensation Board Enforcement Unit.
- What if I pay workers 40 or more hours per week?
- The homeowner affidavit says the exemption form cannot be used in that situation. The homeowner must provide appropriate coverage proof or have the general contractor provide coverage proof or proof of exemption.
Need something notarized?
This Insurance Form for Building Permit Application doesn’t need a notary — but if you have another Russia form that does, a commissioned online notary can help.