Harveys Lake, PA · Luzerne County
Workers’ Compensation Insurance Coverage Information
This form reports a building permit applicant’s workers’ compensation insurance coverage or exemption, and is filed by the applicant with a building permit application.
- 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
This form provides workers’ compensation insurance details or documents an applicant’s claimed exemption from providing coverage. The form says to attach it to a building permit application; complete the insurance sections if the applicant is a contractor covered by the form, or the exemption section if claiming an exemption. Submit it with the building permit application when requested by the municipality.
Who needs it
A building permit applicant who is a contractor must complete the applicable insurance information or exemption section and attach the form to the application.
Why it needs a notary
The form includes a sworn-or-affirmed jurat; the applicant signs before the notary, who completes the date, signature, commission-expiration, and seal fields.
How to get this notarized
- 1
Download The Form
Get the Workers’ Compensation Insurance Coverage Information form.
- 2
Complete The Applicable Section
Enter the applicant and insurance information, or complete the exemption section if claiming an exemption.
- 3
Book An Online Notary
Schedule a session with a commissioned online notary before signing.
- 4
Sign On Video
Sign the form during the online notary session and have the notary complete the jurat.
- 5
Submit With The Application
Attach the notarized form to the building permit application and submit it to the municipality.
Preview the form
The blank PDF straight from Harveys Lake. 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 form?
- Provide the applicant and insurance details, or complete the exemption section if claiming an exemption. Attach the completed form to the building permit application.
- Do I need to sign this form before a notary?
- Yes. The form includes a sworn-or-affirmed statement and a notary block. Sign before the notary, who completes the notarial certificate.
- Can I use a commissioned online notary?
- Pennsylvania authorizes remote online notarization for its commissioned notaries under 57 Pa.C.S. §306.1. A notarial act performed in another state has the same effect under 57 Pa.C.S. §311.
- Where do I submit the completed form?
- The form says to attach it to a building permit application. Ask the municipality where to submit the application, and confirm with the city, borough or township if unsure.
Workers’ Compensation Insurance Coverage Information in other Pennsylvania cities
Each city publishes its own version of this form. Pick the city where you’re filing.