Avondale, PA · Chester County
Workers’ Compensation Exemption Affidavit
This notarized affidavit identifies why workers’ compensation insurance is not required and is completed by an applicant submitting the information with a building permit.
- 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 lets an applicant affirm an exemption from workers’ compensation insurance for one of the listed reasons: the property owner is doing the work, the contractor has no employees, or a religious exemption applies. Use it when applicable to Part C of the workers’ compensation form. The form notes that a contractor hired by a property owner must provide proof of insurance to the municipality, and that religious exemption letters must be attached for all employees.
Who needs it
An applicant claiming a listed workers’ compensation insurance exemption should complete this form when it applies to Part C of the workers’ compensation form.
Why it needs a notary
The applicant signs before a notary, who completes the block stating the affidavit was subscribed, sworn to, and acknowledged before them.
How to get this notarized
- 1
Download the Form
Get the Workers’ Compensation Exemption Affidavit for your building permit paperwork.
- 2
Complete the Affidavit
Identify the applicable exemption reason and prepare any required religious exemption letters for attachment.
- 3
Book an Online Notary
Arrange a session with a commissioned online notary before signing the affidavit.
- 4
Sign on Video
Sign the affidavit during the remote session so the notary can complete the sworn and acknowledged block.
- 5
Submit to the Municipality
Include the notarized affidavit with the workers’ compensation form and building permit materials.
Preview the form
The blank PDF straight from Avondale. 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 Exemption Affidavit?
- Select the applicable reason, complete the applicant information, and sign before the notary. Attach copies of religious exemption letters for all employees if claiming that exemption.
- Do I need to notarize this workers’ compensation form?
- Yes. The form states that it requires a notary seal and must be notarized. The applicant signs before a notary, who completes the sworn and acknowledged block.
- Can I sign this affidavit with a commissioned online notary?
- Pennsylvania authorizes its notaries to perform remote online notarizations under 57 Pa.C.S. §306.1. Check with the municipality that will receive the form to confirm it accepts an online notarization.
- What if I am unsure whether this affidavit applies to my permit?
- The form says to use it when applicable to Part C on the workers’ compensation form. If you are unsure whether it applies or what to submit, confirm with the city, borough or township if unsure.
Workers’ Compensation Exemption Affidavit in other Pennsylvania cities
Each city publishes its own version of this form. Pick the city where you’re filing.