Bethlehem, PA · Lehigh County
Worker’s Compensation Insurance Coverage Information
The Worker’s Compensation Insurance Coverage Information form records an applicant company’s stated reason for not providing coverage, for contractors submitting information to Bethlehem’s Bureau of Code Enforcement.
- 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
Bethlehem’s Bureau of Code Enforcement uses this form to collect applicant and company details when an applicant says it is not required to provide Workers’ Compensation Insurance. The applicant completes Part A and Part B, identifies the applicable reason—such as having no employees or being exempt—and swears or affirms that the statement is true. The form directs applicants in this situation to have it notarized before submitting it.
Who needs it
An applicant who says they are not required to provide Workers’ Compensation Insurance completes this form for Bethlehem’s Bureau of Code Enforcement.
Why it needs a notary
The form carries a “Subscribed and sworn to before me” jurat; the applicant making the exemption statement signs before the notary.
How to get this notarized
- 1
Download the Form
Get the Worker’s Compensation Insurance Coverage Information form from Bethlehem’s Bureau of Code Enforcement.
- 2
Fill In the Applicant Details
Complete Part A with the applicant and company information requested on the form.
- 3
State the Exemption Reason
Complete Part B, indicate the applicable reason, and prepare to swear or affirm that the statement is true.
- 4
Book an Online Notary
Arrange a session with a commissioned online notary before signing the sworn statement.
- 5
Sign on Video
Sign the form during the online notarization session when instructed by the notary.
- 6
Submit to the City
Submit the notarized form to Bethlehem’s Bureau of Code Enforcement.
Preview the form
The blank PDF straight from Bethlehem. 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 Worker’s Compensation coverage form?
- Complete Part A with applicant and company details, then complete Part B by identifying your reason for not providing coverage and signing the sworn statement before a notary.
- Do I need to notarize this form?
- Yes. The form instructs applicants who are not required to provide Workers’ Compensation Insurance to complete Parts A and B and have the form notarized.
- Can I sign the form with an online notary?
- Pennsylvania has authorized remote online notarization for its own notaries since 2020. A notarial act performed elsewhere has the same effect under 57 Pa.C.S. §311. Use a commissioned online notary; confirm with the city, borough or township if unsure.
- Who signs the sworn statement?
- The applicant making the statement about why they are not required to provide Workers’ Compensation Insurance signs the form before the notary.