East Stroudsburg, PA · Monroe County
Workers’ Compensation Exemption Form
Contractors claiming an exemption from providing workers’ compensation insurance complete this form for work under a building permit in East Stroudsburg.
What this form is
Contractors claiming they are not required to provide workers’ compensation insurance complete this form for work under a building permit. The applicant selects a listed reason for the exemption and provides their name, address, county, municipality, signature, and date. The form states that it is good for one year from the date signed.
Who needs it
A contractor claiming an exemption from providing workers’ compensation insurance for work under a building permit needs to complete this form.
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 is signed without a notary; the applicant swears or affirms the stated exemption and signs and dates the form.
How to submit this form
- 1
Download the Form
Download the Workers’ Compensation Exemption Form PDF.
- 2
Complete the Form
Select the exemption reason and fill in your name, address, county, and municipality.
- 3
Sign and Date
Swear or affirm the stated exemption, then sign and date the form.
- 4
Submit to the City
Submit it to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- Who completes the Workers’ Compensation Exemption Form?
- A contractor claiming an exemption from providing workers’ compensation insurance for work under a building permit completes the form.
- What information does the form ask for?
- The applicant selects a listed exemption reason and provides their name, address, county, municipality, signature, and date.
- Do I need a notary for the Workers’ Compensation Exemption Form?
- No. The form is signed without a notary; the applicant swears or affirms the stated exemption and signs and dates it.
- How do I submit the Workers’ Compensation Exemption Form?
- Submit it to the city department named on the form; check the city website for current contact details.
Need something notarized?
This Workers’ Compensation Exemption Form doesn’t need a notary — but if you have another East Stroudsburg form that does, a commissioned online notary can help.