Whitehall, PA · Allegheny County
Workers’ Compensation Information Form
The Workers’ Compensation Information Form records an applicant’s claimed exemption from workers’ compensation coverage for work connected with a Whitehall Borough building permit and is submitted to the municipality.
- 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
This form lets an applicant state why they claim an exemption from providing workers’ compensation insurance: the property owner is doing the work, or the contractor qualifies for a religious exemption. Whitehall Borough requires the form to be completed in front of a notary and to carry a notary seal. The form also explains insurance requirements if a property owner hires a contractor.
Who needs it
Applicants seeking a Whitehall Borough building permit who claim one of the listed workers’ compensation exemptions need to complete this form.
Why it needs a notary
The form has a sworn-and-acknowledged-before-me notarial block, and the applicant signs the exemption statement in front of the notary.
How to get this notarized
- 1
Download the Form
Get the Workers’ Compensation Information Form from Whitehall Borough.
- 2
Fill In the Form
Print your name and title, then indicate the exemption that applies to your work.
- 3
Book an Online Notary
Schedule a session with a commissioned online notary before signing.
- 4
Sign on Video
Sign the form during your online notary session so the notary can complete the notarial block.
- 5
Submit to the Borough
Submit the completed, notarized form to Whitehall Borough for your building permit.
Preview the form
The blank PDF straight from Whitehall. 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 Information Form?
- Print your name and title, select the exemption that applies, and sign in front of a notary. The form says it must be completed in front of a notary and requires a notary seal.
- Do I need to notarize this form?
- Yes. The form states that it requires a notary seal and directs the applicant to complete it in front of a notary.
- Can I sign this form with a commissioned online notary?
- Pennsylvania authorizes remote online notarization for its own notaries under 57 Pa.C.S. §306.1; §311 gives a notarial act performed in another state the same effect as one performed in Pennsylvania.
- What if I hire a contractor to do the permitted work?
- The form says a contractor must provide proof of workers’ compensation insurance to the municipality. For details about your situation, confirm with the city, borough or township if unsure.
Workers’ Compensation Information Form in other Allegheny County cities
Each city publishes its own version of this form. Pick the city where you’re filing.