Worker’s Compensation Insurance Coverage Application

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Applicant

Select Appropriate Option*

Applicant is the property owner and not a contractor within the meaning of the Pennsylvania Workers' Compensation Law

Contractor within the meaning of the Pennsylvania Workers' Compensation Law

Please Note: Documentation shall be also provided for all subcontractors.

Insurance Information

Contractor Name / Policyholder*

Federal or State EIN No.*

Contractor / Policyholder Address*

Street Address City State ZIP Code

Name of Insurer or Self-Insurer*

Insurer or Self-Insurer Address*

Street Address City State ZIP Code

Policy No.*

Policy Expiration Date*

Exemption

The undersigned swears or affirms that he/she is not required to provide workers’ compensation insurance under the provisions of Pennsylvania’s Workers’ Compensation Law for one of the following reasons, as indicated:

Select Appropriate Option*

Property owner performing own work (form to be signed and dated only)

Contractor/Applicant is a sole proprietorship without employees (form shall be signed, dated, and notarized)

Contractor/Applicant’s employees on the project are exempt on religious grounds under Section 304.2 of the Workers’ Compensation Act (form shall be signed, dated, and notarized - attach copies of religious letters for all employees)

Validation and Personal Information

Name*

Phone*

Email*

Proof of Notary*

Download and print out this form to have your notary fill out. Download Form

Drop files here or

Max. file size: 20 MB.

Upload Copies of Religious Letters for all Employees*

Drop files here or

Max. file size: 20 MB.

Signature of Applicant*

Date*

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Comments

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Worker’s Compensation Insurance Coverage Application

Applicant

Insurance Information

Exemption

Validation and Personal Information

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