Southern Pines, NC · Moore County
Affidavit of Workers’ Compensation Coverage
This affidavit reports workers’ compensation coverage for work under a building permit and is completed by the permit applicant, contractor, owner, or 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
Southern Pines requires this affidavit as part of its building permit process. The applicant identifies the permit and their role, then declares under penalties of perjury which workers’ compensation coverage situation applies to the people or businesses doing the permitted work. The form also notes that the town may request certificates of coverage before issuing the permit or while permitted work is underway.
Who needs it
A building permit applicant who is a contractor, owner, or officer or agent completing the form for work covered by the permit needs this affidavit.
How to get this notarized
- 1
Download the Affidavit
Get the Affidavit of Workers’ Compensation Coverage from the Southern Pines Building Permits & Inspections department.
- 2
Fill In the Form
Provide the building permit number, your role, the applicable coverage statement, and other requested details.
- 3
Book an Online Notary
Arrange a session with a commissioned online notary and have the unsigned affidavit ready.
- 4
Sign on Video
Follow the notary’s instructions and sign the affidavit when asked to do so.
- 5
Submit to the City
Submit the completed affidavit with your building permit materials according to the town’s instructions.
Preview the form
The blank PDF straight from Southern Pines. 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 affidavit?
- Enter the building permit number and your role, select the coverage statement that applies, and complete the signature and date. Sign before a commissioned online notary, then submit the form as part of your permit process.
- Do I need to sign this affidavit in front of a notary?
- Yes. The form says it must be signed and sworn before a notary. Wait to sign until your notary instructs you, and follow the town’s submission instructions.
- Can I use remote online notarization for this form?
- North Carolina’s own remote electronic notarization program has not launched. Rush Notary connects signers with a commissioned online notary; confirm with the city or town if unsure whether it will accept your notarized form.
- What workers’ compensation information does the form request?
- It asks the applicant to declare which listed situation applies to the people or businesses doing the permitted work, including employee or subcontractor coverage circumstances.
Other forms in Southern Pines
Affidavit of Workers’ Compensation Coverage in other North Carolina cities
Each city publishes its own version of this form. Pick the city where you’re filing.