Create an Account - Increase your productivity, customize your experience, and engage in information you care about.
(If yes, complete Sections B & C)
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:
Subscribed and sworn to me this _________ Day of _____________________________, 20_______
* indicates a required field