Sellersville, PA · Bucks County
Workers’ Compensation Coverage Information
This one-page workers’ compensation coverage form accompanies a building permit application and is completed by the applicant to report insurance details or claim an exemption from coverage.
- 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
Applicants attach this form to a building permit application to identify whether they are contractors under the Workers’ Compensation Law and, if applicable, provide insurer, policy, and coverage-expiration details. A contractor claiming an exemption completes the sworn section and checks the stated basis: having no employees or qualifying for a religious exemption. The form also notes that a contractor with no employees may be prohibited from working under the permit unless proof of insurance is provided to the Borough.
Who needs it
Building permit applicants who are contractors, including those reporting workers’ compensation coverage or claiming an exemption, should attach this form to their application.
Why it needs a notary
The form has a subscribed-and-sworn jurat; the building-permit applicant signs the exemption statement before a commissioned online notary when claiming an exemption.
How to get this notarized
- 1
Download the Form
Get the Workers’ Compensation Coverage Information form from the Borough’s forms page.
- 2
Fill In the Relevant Sections
Provide applicant and insurance information, or complete the exemption section if claiming an exemption.
- 3
Book an Online Notary
Arrange a remote notarization if you are completing the sworn exemption statement.
- 4
Sign on Video
Sign the exemption statement during your online notary session.
- 5
Submit to the Borough
Attach the completed form to your building permit application and submit it to the Borough.
Preview the form
The blank PDF straight from Sellersville. 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 and submit this form?
- Enter the applicant and insurance details, or complete the sworn exemption section if applicable. Attach the form to your building permit application and submit it to the Borough.
- Do I need to see a notary for this form?
- The notary block is for an applicant swearing or affirming the exemption statement. If you are claiming an exemption, sign that statement before a commissioned online notary.
- Can I sign the exemption section online?
- Pennsylvania authorizes remote online notarization for its own notaries under 57 Pa.C.S. §306.1, in effect since 2020. Confirm with the city, borough or township if unsure.
- What should I include with the building permit application?
- Attach this form to the building permit application. If reporting insurance coverage, the form asks for insurer and policy details and notes that a certificate may be attached.