Forest City, NC · Rutherford County
Affidavit of Workers’ Compensation Coverage
Contractors, owners, or their agents submit this affidavit to report workers’ compensation coverage for work covered by a Forest City building permit.
What this form is
This affidavit reports workers’ compensation coverage for work associated with a Forest City building permit. The applicant identifies whether the contractor or owner has employees or subcontractors and states how coverage applies to them. The Inspections Department may require certificates of coverage before issuing the permit or at any time during the permitted work.
Who needs it
A contractor, owner, or officer or agent applying for a building permit for work in Forest City completes this affidavit.
How to submit it
The form lists the Inspections and Zoning Department at 128 N Powell St, PO Box 728, Forest City, NC 28043, and [email protected].
About notarization
This affidavit does not require a notary; the signer signs and dates it under the stated penalties of perjury.
How to submit this form
- 1
Download The Affidavit
Download the Affidavit of Workers’ Compensation Coverage PDF.
- 2
Complete The Affidavit
Enter the building permit number and address, identify your role, and state how workers’ compensation coverage applies.
- 3
Gather Coverage Certificates
Be prepared to provide certificates of coverage if the Inspections Department requires them.
- 4
Submit To The Department
Submit the completed affidavit to the Inspections and Zoning Department using the address or email listed on the form.
Frequently asked questions
- What does the workers’ compensation coverage affidavit report?
- It asks the applicant to state whether the contractor or owner has employees or subcontractors and how workers’ compensation coverage applies to them.
- Who completes this Forest City affidavit?
- The building-permit applicant completes it as a contractor, owner, or officer or agent of the contractor or owner.
- Do I need a notary for the workers’ compensation affidavit?
- No. The affidavit does not require a notary; the signer signs and dates it under the stated penalties of perjury.
- How do I submit the workers’ compensation affidavit?
- The form lists the Inspections and Zoning Department address and [email protected]. The department may require certificates of coverage before permit issuance or during the permitted work.
Need something notarized?
This Affidavit of Workers’ Compensation Coverage doesn’t need a notary — but if you have another Forest City form that does, a commissioned online notary can help.