Bryn Athyn, PA · Montgomery County
Workers’ Compensation Coverage Information Form
This form documents a building permit applicant’s or contractor’s workers’ compensation insurance coverage or claimed exemption, and is filed with the 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
The form identifies whether the applicant or contractor is covered by workers’ compensation insurance, is a qualified self-insurer, or claims an exemption. It asks for insurance details or the reason for exemption, with supporting certificates or letters where indicated. The form states that it should be attached to the Building Permit Application, so complete the applicable sections and submit it with that application.
Who needs it
Building permit applicants or contractors must complete this form to provide workers’ compensation coverage information or state an applicable exemption.
Why it needs a notary
The form carries a subscribed, sworn-to-and-acknowledged-before-me block; the applicant signs the applicable information and exemption declaration before the notary.
How to get this notarized
- 1
Download The Form
Download the Workers’ Compensation Coverage Information Form and review its sections and instructions.
- 2
Complete Applicable Sections
Enter applicant and contractor details, provide coverage information or identify the applicable exemption, and attach documents indicated by the form.
- 3
Book An Online Notary
Schedule an online notarization with a commissioned online notary.
- 4
Sign On Video
Show identification and sign the form during the video session when instructed by the notary.
- 5
Submit With Your Application
Attach the completed form to your Building Permit Application and submit it to the municipality.
Preview the form
The blank PDF straight from Bryn Athyn. 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
- What is the Workers’ Compensation Coverage Information Form for?
- It records workers’ compensation insurance or self-insurance information, or a claimed exemption, for attachment to a Building Permit Application.
- Who completes this form?
- The building permit applicant or contractor provides the requested coverage information and completes the applicable sections based on the form’s instructions.
- How do I get this form notarized online?
- Complete the applicable sections, book with a commissioned online notary, and sign during the video session when instructed. Submit the notarized form with your Building Permit Application.
- Do I need to attach supporting documents?
- The form calls for a certificate for qualified self-insurers and indicates that religious exemption letters for all employees should be attached when that exemption is claimed.
- Can I sign this form with an online notary?
- Since 2020, Pennsylvania authorizes remote online notarization for its own notaries under 57 Pa.C.S. §306.1. Confirm with the city, borough or township if unsure whether it accepts the notarized form.
Workers’ Compensation Coverage Information Form in other Pennsylvania cities
Each city publishes its own version of this form. Pick the city where you’re filing.