Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

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: