WORKER’S COMPENSATION INSURANCE COVERAGE INFORMATION

(attach to Stroud Township Zoning Permit Application)

A.  The applicant is a Contractor within the meaning of the Pennsylvania Workers’ Compensation Law  ___Yes     ___No

                        If the answer is “Yes”, please complete Sections B and C below as appropriate.

 

                    B.  Insurance Information

 

            Name of Applicant:                                                                                                                 

            Federal or State Employer Identification Number:                                                                 

            Applicant is a qualified self-insurer for workers’ compensation:

            ___  Certificate attached

            Policy expiration date:                                                

 

 

              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 workers’ compensation insurance under the provisions of Pennsylvania’s Workers’ Compensation Law for one of the following reasons, as indicated:

 

          ___  Contractor with no employees.  Contractor is prohibited by law from employing any individual to perform work pursuant to this building permit unless contractor provides proof of insurance to the township.

       

          ___  Religious exemption under the Workers’ Compensation Law.

 

 

 

 Subscribed and sworn before me this

                Day of                                20                ­­

 

                                                                               

              Signature of Notary Public

 

My Commission expires:                                                                                   Signature of Applicant:                                      

                (Seal)                                                                                                     Address:                                                               

                                                                                                                                                                                                               

                                                                                                                                County:                                                                 

                                                                                                                                Municipality:                                                         

               

 link for Plot Plan requirements sheet