Rushville, NY · Yates County
Affidavit of Exemption from Workers’ Compensation Insurance Proof
This affidavit lets an owner of a 1–4 family, owner-occupied residence explain why workers’ compensation insurance proof is not required for work covered by a building permit.
- 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
A homeowner applying for a building permit uses this affidavit to certify an applicable reason for not providing specific proof of workers’ compensation insurance coverage. The form lists options involving the owner doing all the work, unpaid workers, or limited paid work hours with homeowners’ insurance. It also describes what the owner or general contractor agrees to provide if the project reaches 40 or more aggregate paid-worker hours per week.
Who needs it
An owner applying for a building permit for a 1–4 family, owner-occupied residence may use this form if one of its listed exemptions applies.
How to get this notarized
- 1
Download the Form
Get the workers’ compensation exemption affidavit from the village form source.
- 2
Fill In the Affidavit
Provide the requested details and check the exemption that applies to your project.
- 3
Book an Online Notary
Arrange a remote notarization with a commissioned online notary.
- 4
Sign on Video
Sign the affidavit during the video session when the notary instructs you.
- 5
Submit to the Village
File the notarized affidavit with your building permit materials as directed by the permit-issuing office.
Preview the form
The blank PDF straight from Rushville. 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 this workers’ compensation exemption affidavit?
- Enter the requested information, select the exemption that applies, and sign before a notary or county clerk. Submit the completed affidavit with your building permit materials.
- Do I need to sign this affidavit in front of a notary?
- Yes. The form includes a “Sworn to before me” jurat, so the homeowner must sign in front of a notary or county clerk.
- Can I use a commissioned online notary for this affidavit?
- New York authorizes remote online notarization by its own notaries under Executive Law §135-c, effective since 2023. A commissioned online notary can notarize your signature during a video session.
- What if I’m unsure whether the village will accept my completed form?
- Ask the permit-issuing office about its submission requirements before filing; confirm with the city, town or village if unsure.
Affidavit of Exemption from Workers’ Compensation Insurance Proof in other New York cities
Each city publishes its own version of this form. Pick the city where you’re filing.