"*" indicates required fields ApplicantSelect 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 InformationContractor 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* ExemptionThe 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 InformationName* Phone* Email* Proof of Notary*Download and print out this form to have your notary fill out. Download Form Drop files here or Select files Max. file size: 20 MB. Upload Copies of Religious Letters for all Employees* Drop files here or Select files Max. file size: 20 MB. Signature of Applicant* Date* CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ
