Blawnox, PA · Allegheny County
Workers’ Compensation Affidavit of Exemption
This one-page Workers’ Compensation Affidavit of Exemption lets a property owner or contractor state why workers’ compensation coverage is not required when applying for a Blawnox building permit.
- 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
The form records why the signer claims an exemption from workers’ compensation insurance, with options for a property owner doing their own work, a contractor with no employees, or a religious exemption. Use it when applicable to part C of the workers’ compensation form for a building permit. The form notes that a contractor hired by a property owner must provide proof of insurance to the municipality, and religious exemptions require supporting letters.
Who needs it
A property owner or contractor applying for a Blawnox building permit may need this form when claiming an exemption from workers’ compensation insurance requirements.
Why it needs a notary
The form includes a subscribed, sworn, and acknowledged before me block; the applicant named above signs and swears to the exemption before the notary.
How to get this notarized
- 1
Download the Affidavit
Get the Blawnox Workers’ Compensation Affidavit of Exemption from the Borough’s form page.
- 2
Choose and Fill In the Form
Select the exemption reason that applies and complete the county and municipality information.
- 3
Book an Online Notary
Schedule a session with a commissioned online notary and have your identification ready.
- 4
Sign on Video
Sign and swear to the affidavit during the online notary session; attach religious exemption letters if applicable.
- 5
Submit to the Borough
Submit the notarized affidavit with the applicable workers’ compensation form for your building permit.
Preview the form
The blank PDF straight from Blawnox. 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 the Workers’ Compensation Affidavit of Exemption?
- Select the exemption reason that applies, provide the requested county and municipality information, and sign the affidavit before a notary. Attach religious exemption letters when that option applies.
- Do I need to have this form notarized?
- Yes. The form states that it requires a notary seal and includes a subscribed, sworn, and acknowledged before me block for the applicant’s signature.
- Can I use an online notary for this affidavit?
- Pennsylvania authorizes its own notaries to perform remote online notarizations under 57 Pa.C.S. §306.1. Under §311, an act performed in another state has the same effect as one performed by a notary in Pennsylvania.
- Where do I submit the completed affidavit?
- The form identifies the municipality as the recipient of workers’ compensation insurance proof and says to use this affidavit when applicable to part C of the workers’ compensation form. Confirm submission details with the Borough.