East Stroudsburg, PA · Monroe County
Workers’ Compensation Exemption Form
Contractors use this form to claim an exemption from providing workers’ compensation insurance for work under a building permit.
What this form is
This form is for a contractor claiming exemption from providing workers’ compensation insurance. The contractor indicates whether they have no employees, are prohibited by law from employing anyone for work under the building permit without proof of insurance, or claim a religious exemption. It asks for the applicant’s name, address, county, municipality, signature, and date, and states that it is good for one year from the date signed.
Who needs it
A contractor claiming one of the listed exemptions from providing workers’ compensation insurance completes and signs 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; it says the contractor swears or affirms an exemption, but includes no separate notarized attachment or step.
How to submit this form
- 1
Download The Form
Download the Workers’ Compensation Exemption Form.
- 2
Complete The Form
Select the applicable exemption reason and fill in the applicant’s 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 should complete the Workers’ Compensation Exemption Form?
- A contractor claiming an exemption from providing workers’ compensation insurance should complete the form and indicate the applicable reason.
- What information does the form ask for?
- It asks for the applicant’s name, address, county, municipality, signature, and date. The contractor also selects a listed exemption reason.
- Do I need a notary for the Workers’ Compensation Exemption Form?
- No. The form has a signature and date line but no notary block. It says the contractor swears or affirms an exemption, with no separate notarized attachment or step.
- 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.