Workers' Compensation Insurance Coverage Information

2. A. The applicant is a contractor within the meaning of the Pennsylvania Worker's Compensation Law.

   1. No
   2. Yes

   (If yes, complete Sections B & C)

4. B. Insurance Information

6. Name of Applicant:

8. Business Name:

10. Address1

12. Address2

14. City

15. State

16. ZIP

18. Phone:

19. Pager/Cell Phone:

21. Federal or State Employer Identification No.:

23. **If the applicant is a qualified self-insurer for Workers' Compensation, attach certificate.

25. Name of Work Compensation Insurer:

27. Workers' Compensation Insurance Policy #:

28. Policy Expiration Date:

30. 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:

    1. Contractor with no employees. Contractor prohibit by law from employing any individual to perform work pursuant to this Permit unless contractor provides proff of insurance to the Township.
    2. Religious exemption under the Workers' Compensation Law.
32. Subscribed and sworn to me this _________ Day of _____________________________, 20_______

    Subscribed and sworn to me this _________ Day of _____________________________, 20_______

34. My commission expires:

36. Signature of Applicant:

38. Address1

40. Address2

42. City

43. State

44. ZIP

46. County of:

47. Municipality of:

49. **Attach permit to application**

Leave This Blank:


50. Print Only

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