Patterson Heights, PA · Beaver County
Workers’ Compensation Information Form – Affidavit of Exemption
This one-page affidavit lets a building permit applicant affirm an exemption from workers’ compensation insurance and requires notarization before submission 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
The form is an affidavit of exemption for an applicant who says they are not required to provide workers’ compensation insurance under one of the listed reasons. It addresses property owners doing their own work, contractors without employees, legal restrictions on employing workers, and religious exemptions. Use it when applicable to part C on the workers’ compensation form; the form says it requires a notary seal.
Who needs it
Applicants using an exemption reason listed on this form for a building permit must complete it when applicable to part C of the workers’ compensation form.
How to get this notarized
- 1
Download the Form
Get the Workers’ Compensation Information Form – Affidavit of Exemption.
- 2
Complete the Form
Enter the applicant and municipality information and indicate the applicable exemption reason.
- 3
Book an Online Notary
Arrange a remote notarization with a commissioned online notary.
- 4
Sign on Video
Sign and swear to the affidavit during the online notary session.
- 5
Submit to the Municipality
Submit the notarized form with the workers’ compensation form as applicable to part C.
Preview the form
The blank PDF straight from Patterson Heights. 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?
- Select the applicable exemption reason, complete the applicant and municipality information, then sign and swear to the affidavit before a notary. The form says to use it when applicable to part C on the workers’ compensation form.
- Do I need to sign this form in front of a notary?
- Yes. The form says it requires a notary seal and includes a subscribed, sworn-to, and acknowledged-before-me block. Pennsylvania law authorizes a commissioned online notary to perform remote notarizations under 57 Pa.C.S. §306.1.
- Who can use an exemption listed on this form?
- The listed reasons include a property owner performing their own work, a contractor with no employees, a contractor prohibited by law from employing anyone for the permitted work, and a religious exemption.
- What if a property owner hires a contractor?
- The form says the contractor must provide proof of workers’ compensation insurance to the municipality, and the homeowner assumes liability for contractor compliance with these requirements. Confirm with the city, borough or township if unsure.
Workers’ Compensation Information Form – Affidavit of Exemption in other Pennsylvania cities
Each city publishes its own version of this form. Pick the city where you’re filing.