Winston-Salem, NC · Forsyth County
Affidavit of Worker’s Compensation Coverage
Contractors or owner applicants complete this affidavit to report workers’ compensation coverage or an applicable exemption for work under a building permit.
What this form is
This affidavit records the workers’ compensation coverage status of the people or businesses performing work under a building permit, along with the applicant’s applicable contractor or owner status. The form asks for the permit number, firm name, signer’s title, signature, and date, and includes statements about employees, subcontractors, insurance, and licensing. The Inspections Division may require coverage certificates or waivers before issuing the permit.
Who needs it
The person, firm, or corporation listed as the contractor on the building permit must sign the affidavit for the permit application.
How to submit it
The form lists Planning & Development Services at Suite 328, Bryce A. Stuart Municipal Building, 100 East First Street, Winston-Salem, NC 27101, and P.O. Box 2511, Winston-Salem, NC 27102-2511.
About notarization
This document is signed without a notary; it contains a sworn statement under penalties of perjury, but the signer just signs and dates the form.
How to submit this form
- 1
Download The Affidavit
Download the fillable Worker’s Compensation Coverage Affidavit.
- 2
Complete The Form
Enter the permit and applicant information, indicate the applicable coverage or licensing statements, and provide the firm name and signer’s title.
- 3
Gather Coverage Documents
The Inspections Division may require certificates of coverage or waivers of workers’ compensation insurance coverage before permit issuance.
- 4
Sign And Submit
Have the contractor named on the building permit sign and date the form, then use the Planning & Development Services address listed on it.
Frequently asked questions
- Do I need a notary for the Worker’s Compensation Coverage Affidavit?
- No. The form has no notary block; it includes a sworn statement under penalties of perjury, and the signer signs and dates it.
- Who signs the Worker’s Compensation Coverage Affidavit?
- The form says it must be signed by the person, firm, or corporation appearing as the contractor on the building permit.
- What information does the affidavit ask for?
- It asks for the building permit number and information about the applicant, contractor, employees, subcontractors, workers’ compensation coverage, and applicable licensing or exemptions.
- How do I submit the Worker’s Compensation Coverage Affidavit?
- The form lists Planning & Development Services at Suite 328, Bryce A. Stuart Municipal Building, 100 East First Street, Winston-Salem, NC 27101, and a P.O. Box address.
Need something notarized?
This Affidavit of Worker’s Compensation Coverage doesn’t need a notary — but if you have another Winston-Salem form that does, a commissioned online notary can help.