Boiling Spring Lakes, NC · Brunswick County
Workers’ Compensation Affidavit
This affidavit states the workers’ compensation coverage status of people performing permitted work and is completed by the applicant, contractor, property owner, or their officer or agent.
- 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
The form asks the applicant to identify the permit address and parcel number, select the applicable statement about employees, subcontractors, and workers’ compensation coverage, and sign under penalties of perjury. The City’s Inspections Department uses it with a permit application and may require insurance certificates before issuing the permit or while permitted work is underway.
Who needs it
A permit applicant who is a contractor, property owner, or their officer or agent completes this affidavit for work covered by the permit.
How to get this notarized
- 1
Download the Affidavit
Get the Workers’ Compensation Affidavit from the City of Boiling Spring Lakes.
- 2
Complete the Form
Fill in the permit address, parcel number, applicant role, and applicable coverage statement.
- 3
Book a Notary
Arrange a time with a commissioned online notary if online notarization is available for your situation.
- 4
- 5
Submit to the City
Send the notarized affidavit with your permit application to the City’s Inspections Department.
Preview the form
The blank PDF straight from Boiling Spring Lakes. 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 the workers’ compensation affidavit?
- Enter the permit address and parcel number, identify your role, select the statement that applies, and complete the signature and date. Sign before the notary, then submit the form with your permit materials.
- Do I need to sign this form in front of a notary?
- Yes. The form includes a jurat stating that the affidavit was sworn and subscribed before a notary. Wait to sign until you are with the notary.
- Can I use online notarization for this affidavit?
- North Carolina’s remote electronic notarization program has not launched. Emergency video notarization requires both the signer and notary to be in North Carolina; it is not remote online notarization. Ask the city about acceptable options.
- What if I am unsure which coverage statement to select?
- The form offers choices based on employees, subcontractors, and workers’ compensation coverage. Review the options that match your situation, and confirm with the city or town if unsure.
Workers’ Compensation Affidavit in other North Carolina cities
Each city publishes its own version of this form. Pick the city where you’re filing.