How do I submit the Workers' Compensation Exemption Form?

Apply through New York Business Express, attest and submit the application, then print and sign the certificate and provide it to the government entity issuing the permit, license, or contract.

Who can apply for a certificate of exemption?

The application provides options to apply as a business or as a homeowner obtaining permits to work on the homeowner's residence.

Can I use the certificate for another business?

No. The document says the certificate may be used only to show a government entity that the specified insurance is not required, not to another business or its insurance carrier.

Webster, NY · Monroe County

No notary required

Workers' Compensation Exemption Form

This application lets a business or qualifying homeowner request a certificate showing an exemption from specified workers’ compensation or disability and paid family leave insurance requirements.

What this form is

Applicants complete the Certificate of Attestation of Exemption through New York Business Express when requesting a permit, license, or contract from a government entity. The application asks for business and certificate-holder details, work location and estimated dates, and the reason for the claimed exemptions. The certificate may be provided only to a government entity, and it is not accepted one year after its printed date.

Who needs it

A business or qualifying homeowner seeking a permit, license, or contract may apply when claiming the stated insurance exemption.

How to submit it

Apply through New York Business Express by completing the application screens, reviewing the summary, and attesting and submitting. Print and sign the certificate, then provide it to the government entity issuing the permit, license, or contract.

About notarization

This document is signed without a notary; the applicant affirms the statements under penalties of perjury and prints and signs the certificate.

How to submit this form

1
Download the Form
Download the Workers' Compensation Exemption Form from this page.
2
Complete the Application
Apply through New York Business Express as a business or qualifying homeowner, complete the application screens, and review the summary.
3
Attest and Submit
Attest to the application and submit it through New York Business Express.
4
Print, Sign, and Provide the Certificate
Print and sign the certificate, then provide it to the government entity issuing the permit, license, or contract.

Frequently asked questions

Do I need a notary for the Workers' Compensation Exemption Form?: No. The document is signed without a notary, but the applicant affirms the statements under penalties of perjury and prints and signs the certificate.
How do I submit the Workers' Compensation Exemption Form?: Apply through New York Business Express, attest and submit the application, then print and sign the certificate and provide it to the government entity issuing the permit, license, or contract.
Who can apply for a certificate of exemption?: The application provides options to apply as a business or as a homeowner obtaining permits to work on the homeowner's residence.
Can I use the certificate for another business?: No. The document says the certificate may be used only to show a government entity that the specified insurance is not required, not to another business or its insurance carrier.

Need something notarized?

This Workers' Compensation Exemption Form doesn’t need a notary — but if you have another Webster form that does, a commissioned online notary can help.