Fayetteville, NC · Cumberland County
Affidavit of Workers’ Compensation Coverage
Contractors, owners, and their officers or agents use this affidavit to report workers’ compensation coverage for work covered by a permit.
What this form is
This affidavit records whether the people performing permitted work have workers’ compensation insurance, subcontractor coverage, or no more than two employees and no subcontractors. The form is marked for projects of $40,000 or more and asks for the job location, applicant’s role, coverage details, firm name, printed name, signature, title, and date. Development Services may request coverage certificates or waivers.
Who needs it
A contractor, owner, or officer or agent applying for a permit for a project marked as $40,000 or more may need to complete this affidavit.
How to submit it
The form names the Development Services Department as the department issuing the permit and says it may request coverage documents. Submit the affidavit with the permit application to that department; the form gives no address or email.
About notarization
This document is signed without a notary; the signer affirms under penalties of perjury and signs and dates the form.
How to submit this form
- 1
Download The Affidavit
Download the Workers’ Compensation Coverage Affidavit PDF.
- 2
Complete The Form
Enter the job location, applicant role, coverage details, firm name, printed name, title, and date, then sign.
- 3
Gather Coverage Documents
The Development Services Department may request certificates of coverage or waivers.
- 4
Submit With The Permit
Submit the affidavit with the permit application to the Development Services Department.
Frequently asked questions
- Do I need a notary for the Workers’ Compensation Coverage Affidavit?
- No. The form has no notary block; the signer affirms under penalties of perjury and signs and dates it.
- Who completes this affidavit?
- The applicant may be the contractor, owner, or an officer or agent of the contractor or owner. The form asks the applicant to identify their role.
- What information does the affidavit ask for?
- It asks for the job location, applicant’s role, workers’ compensation coverage details, firm name, printed name, signature, title, and date.
- How do I submit the affidavit?
- Submit it with the permit application to the Development Services Department, which the form identifies as the department issuing the permit. The form provides no address or email.
Need something notarized?
This Affidavit of Workers’ Compensation Coverage doesn’t need a notary — but if you have another Fayetteville form that does, a commissioned online notary can help.