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Workers' Compensation Insurance Coverage Information

  1. A. The applicant is a contractor within the meaning of the Pennsylvania Worker's Compensation Law.
    (If yes, complete Sections B & C)
  2. B. Insurance Information
  3. **If the applicant is a qualified self-insurer for Workers' Compensation, attach certificate.
  4. C. Exemption
    Complete Section "C" if the applicant is a contractor claiming exemption from providing Workers' Compensation Insurance. The undersigned swears or affirms that he/she is not required to provide Worker's Compensation Insurance under the provision of Pennsylvania's Workers' Compensation Law for one of the following reasons:
  5. Subscribed and sworn to me this _________ Day of _____________________________, 20_______
  6. **Attach permit to application**
  7. Leave This Blank: