Rockingham, NC · Richmond County
Workers’ Compensation Insurance Statement
Contractors, owners, or their agents use this statement with a building permit to declare workers’ compensation coverage for people performing the permitted work.
What this form is
The statement records the applicant’s role and the workers’ compensation coverage status of people performing work under a building permit. It asks for the permit number, firm name, signer’s title, and date, and includes declarations about employees, subcontractors, and insurance. The Inspection Department may require certificates of insurance coverage before issuing the permit or during the permitted work.
Who needs it
A contractor, owner, or authorized agent applying for a building permit uses this statement to report workers’ compensation coverage for the project.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This document is signed without a notary; the signer makes a declaration under penalties of perjury and signs and dates the statement.
How to submit this form
- 1
Download The Statement
Download the workers’ compensation statement PDF.
- 2
Complete The Statement
Enter the building permit number, firm name, signer’s title, and date, and complete the applicable coverage declaration.
- 3
Gather Coverage Certificates
The Inspection Department may require certificates of workers’ compensation insurance coverage before permit issuance or during the permitted work.
- 4
Submit To The City
Submit the completed statement to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- Do I need a notary for the workers’ compensation statement?
- No. The form has no notary block; the signer signs and dates a declaration under penalties of perjury.
- Who completes this workers’ compensation statement?
- The applicant for a building permit completes it as the contractor, owner, or officer or agent of the contractor or owner.
- What information does the statement request?
- It requests the building permit number, firm name, signer’s title, and date, along with declarations about employees, subcontractors, and workers’ compensation coverage.
- How do I submit the workers’ compensation statement?
- The document does not provide submission contact details. Submit it to the city department named on the form and check the city website for current contact details.
Need something notarized?
This Workers’ Compensation Insurance Statement doesn’t need a notary — but if you have another Rockingham form that does, a commissioned online notary can help.