Greenville, NC · Pitt County
Affidavit of Workers’ Compensation Coverage
This affidavit lets a building permit applicant state the workers’ compensation coverage status of the people performing work under the permit.
What this form is
A contractor, owner, or contractor or owner representative uses this affidavit when applying for a building permit. The signer identifies the firm and attests to the workers’ compensation coverage situation for the people performing the permitted work, including employee and subcontractor coverage. The Inspection Department issuing the permit may require certificates of insurance coverage before the permit is issued or while the permitted work is underway.
Who needs it
A contractor, owner, or contractor or owner representative applying for a building permit and attesting to workers’ compensation coverage needs this affidavit.
How to submit it
Submit it to the Inspection Department issuing the building permit; check the city website for current contact details and any certificate requirements.
About notarization
This affidavit is signed and dated without a notary; the signer just signs and dates it, and the Inspection Department may require insurance certificates.
How to submit this form
- 1
Download The Affidavit
Download the Workers’ Compensation Coverage Affidavit PDF.
- 2
Complete The Affidavit
Enter the building permit number and firm name, identify your role, and complete the coverage attestation.
- 3
Sign And Date
The signer signs and dates the affidavit; no notary is required.
- 4
Submit To The City
Submit it to the Inspection Department issuing the building permit and check whether insurance certificates are required.
Frequently asked questions
- Do I need a notary for the Workers’ Compensation Coverage Affidavit?
- No. The document has no notary block; the signer signs and dates it. The Inspection Department may require workers’ compensation insurance certificates.
- Who completes this affidavit?
- The building permit applicant completes it as the contractor, owner, or an officer or agent of the contractor or owner.
- What does the affidavit ask the signer to attest to?
- It asks the signer to state the workers’ compensation coverage situation for the people performing work under the permit, including employees and subcontractors.
- How do I submit the Workers’ Compensation Coverage Affidavit?
- Submit it to the Inspection Department issuing the building permit. Check the city website for current contact details and any certificate requirements.
Need something notarized?
This Affidavit of Workers’ Compensation Coverage doesn’t need a notary — but if you have another Greenville form that does, a commissioned online notary can help.