Hollidaysburg, PA · Blair County
Contractor’s Certification of Workman’s Compensation Insurance Coverage
Contractors complete this certification for a building permit to provide workers’ compensation insurance information or declare that they will not hire others.
What this form is
This form records whether the building permit applicant is a contractor subject to workers’ compensation requirements. Applicants who answer yes provide insurance or self-insurance information and indicate that a certificate is attached; applicants who answer no complete the exemption statement. The exemption statement says the signer will notify the office and provide proof of coverage within three working days if they later hire others for the project.
Who needs it
A contractor seeking a building permit uses this form to provide workers’ compensation coverage information or complete the exemption statement.
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; Section C contains a sworn statement, and the signer signs and dates the form.
How to submit this form
- 1
Download The Form
Download the workers’ compensation certification PDF.
- 2
Complete The Applicable Section
Indicate whether you are a contractor, then complete Section B or Section C as directed.
- 3
Gather The Certificate
If applicable, attach the workers’ compensation insurance or self-insurance certificate indicated in Section B.
- 4
Sign And Submit
Sign and date the form, then submit it to the city department named on the form.
Frequently asked questions
- Do I need a notary for the workers’ compensation certification?
- No. The form has no notary block; Section C contains a sworn statement that the signer signs and dates.
- How do I submit the certification?
- Submit it to the city department named on the form; check the city website for current contact details.
- What information does the form request?
- It asks whether the applicant is a contractor and, if so, requests employer identification and workers’ compensation insurer, policy, and expiration details.
- What does the exemption statement require?
- The signer states they will not hire others for the project. If they later do, they agree to notify the office and provide proof of coverage within three working days.