Yardley, PA · Bucks County
Workers Compensation Coverage Information and Affidavit
This form reports workers’ compensation coverage or an exemption for a Yardley building-permit applicant, including contractors and homeowners performing the work themselves.
At a glance
- Issued by
- City of Yardley · Yardley, Bucks County, Pennsylvania
- Notarization
- Required: sign this form in front of a notary before filing it.
- Official source
- yardleyboro.org
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
- 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
Yardley Borough uses this attachment with a building permit application to collect applicant details and information about workers’ compensation insurance or qualified self-insurance. A contractor claiming an exemption, or a homeowner performing the work without hiring anyone, must complete the affidavit in Section D. The affidavit states that the signer will not employ anyone for the project and explains the duty to notify the Borough and provide coverage proof if that changes.
Who needs it
Building-permit applicants who are contractors or homeowners performing the work must complete the applicable sections; homeowners hiring a contractor forward the application to that contractor.
How to get this notarized
- 1
Download the Form
Download Yardley Borough’s workers’ compensation coverage form and review the instructions for the building-permit applicant.
- 2
Complete the Applicable Sections
Enter applicant and insurance details, and complete Section D if the form’s instructions apply to your situation.
- 3
Book an Online Notary
If Section D requires notarization, book a commissioned online notary and have your identification ready.
- 4
Sign on Video
Sign and swear to the Section D affidavit during the online notary session.
- 5
Submit to the Borough
Submit the completed form with your building-permit application to Yardley Borough.
Preview the form
The blank PDF straight from Yardley. 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 Yardley workers’ compensation form?
- Fill in the applicant and insurance information that applies. If Section D applies, complete the affidavit and sign it before a commissioned online notary, then submit the form with your building permit application.
- Do I need to notarize this form?
- Section D must be notarized when a contractor claims an exemption or a homeowner will perform the work without hiring anyone. The form directs other homeowners to forward the application to the contractor doing the work.
- Can I sign Section D with an online notary?
- Pennsylvania authorizes commissioned online notaries to perform remote online notarizations under 57 Pa.C.S. §306.1. Check that Yardley Borough will accept an online-notarized affidavit before booking.
- What if I am unsure whether Section D applies?
- The form makes Section D depend on whether a contractor claims an exemption or a homeowner will perform the work without hiring anyone. Confirm with the city, borough or township if unsure.
Workers Compensation Coverage Information and Affidavit in other Pennsylvania cities
Each city publishes its own version of this form. Pick the city where you’re filing.