Paxtang, PA · Dauphin County
Contractors Workers’ Compensation Insurance Coverage Information
Contractors working on a project complete this form to provide workers’ compensation insurance information or claim an exemption, and attach it to a building permit application.
What this form is
This form provides workers’ compensation coverage information for contractors working on a project and is attached to a building permit application. It asks for applicant and employer identification details, insurer and policy information, and the policy expiration date; applicants claiming an exemption state the applicable reason, and all contractors working on the project sign.
Who needs it
Each contractor working on the project must complete and sign this page, providing insurance details or stating a workers’ compensation exemption reason.
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 form has no notary block; contractors sign it, and an applicant claiming an exemption swears or affirms the stated basis.
How to submit this form
- 1
Download The Form
Download the Contractors Workers’ Compensation Insurance Coverage Information PDF.
- 2
Complete The Applicable Sections
Provide applicant and insurance details, or state the applicable reason if claiming an exemption.
- 3
Gather Attachments
Attach the workers’ compensation certificate if applicable, along with this page to the building permit application.
- 4
Sign And Submit
Have all contractors working on the project sign, then submit the page with the building permit application.
Frequently asked questions
- What is the Contractors Workers’ Compensation Insurance Coverage Information form?
- It collects workers’ compensation insurance details or an exemption reason from contractors working on a project. Attach it to a building permit application.
- Who must complete this form?
- All contractors working on the project must sign the page. Contractors provide insurance information or, if claiming an exemption, state the applicable reason.
- Do I need a notary for the Contractors Workers’ Compensation Insurance Coverage Information form?
- No. The form has no notary block. Contractors sign it; an applicant claiming an exemption swears or affirms the stated basis.
- How do I submit the Contractors Workers’ Compensation Insurance Coverage Information form?
- The form says to attach this page to the building permit application. It does not list a submission address or department, so check the city website for current contact details.