East Stroudsburg, PA · Monroe County
Workers’ Compensation Exemption Form
Contractors claiming an exemption from workers’ compensation insurance complete this form for the Borough of East Stroudsburg.
What this form is
A contractor uses this form to state that they are exempt from providing workers’ compensation insurance for one of the reasons listed. It asks the applicant to identify the exemption, provide a name and address, specify the county and municipality, and sign and date the form. The form states it is good for one year from the date signed.
Who needs it
A contractor applying for a building permit who claims one of the listed reasons for not providing workers’ compensation insurance needs 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 document is signed without a notary; the applicant swears or affirms the stated exemption, then signs and dates the form.
How to submit this form
- 1
Download The Form
Download the Workers’ Compensation Exemption Form.
- 2
Complete The Exemption Details
Indicate the applicable exemption and fill in your name, address, county, and municipality.
- 3
Sign And Date
Sign and date the form; it states that it is good for one year from the date signed.
- 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 completes the form for the Borough.
- What information does the form request?
- It asks the applicant to indicate a listed exemption, provide a name, address, county, and municipality, and sign and date the form.
- Do I need a notary for the Workers’ Compensation Exemption Form?
- No. The form has no notary block; 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.