Chester, NY · Warren County
Workers’ Compensation Exemption Affidavit
This affidavit is for homeowners of one- to four-family owner-occupied residences who apply for a building permit and qualify for a workers’ compensation exemption.
What this form is
Homeowners use this affidavit when applying for a building permit for a one- to four-family owner-occupied residence and qualifying for an exemption from showing specific workers’ compensation insurance proof. The form asks the homeowner to select the applicable work or hiring situation, certify ownership, sign and date, and provide a telephone number and property address. It also describes coverage requirements if paid work reaches 40 hours or more per week.
Who needs it
A homeowner listed as the general contractor on a building permit may use this form for a one- to four-family owner-occupied residence if one of its exemption conditions 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, so the signer signs and dates it; it states that a 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 Workers’ Compensation Exemption Affidavit PDF.
- 2
Complete The Form
Select the applicable exemption condition, certify ownership, and enter the requested contact and property details.
- 3
Review Related Requirements
Check the form’s instructions about workers’ compensation proof if paid work reaches 40 hours or more per week.
- 4
Sign And Submit
Sign and date the affidavit, then submit it to the city department named on the form.
Frequently asked questions
- Who can use the Workers’ Compensation Exemption Affidavit?
- It is for homeowners of one- to four-family owner-occupied residences who are listed as the general contractor on a building permit and meet an exemption condition.
- Do I need a notary for the Workers’ Compensation Exemption Affidavit?
- No notary block appears on this document, so the signer signs and dates it. The text says a 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.