Contractor’s Certification of Workman’s Compensation Insurance Coverage
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Document Overview
This is a form from The Borough of Hollidaysburg, PA titled “Workers Compensation Coverage Insurance Information.” It is used to verify whether a contractor has workers’ compensation insurance as required by Pennsylvania law.
Key Sections & Requirements
Section A: Contractor Status Question
- Asks: Is the applicant a contractor under Pennsylvania Workers Compensation Law?
- If YES → Complete Section B (Insurance Information)
- If NO → Complete Section C (Exemption)
Section B: Insurance Information (for contractors who answered YES)
Required fields:
- Applicant Name
- Federal or State Employer Identification Number
- Whether applicant is a qualified self-insurer (with certificate attached if yes)
- Name of Workers Compensation Insurer
- Policy Number
- Certificate attached? (Yes/No)
- Policy Expiration Date
Section C: Exemption (for those who answered NO)
Applicant must swear under oath that they will not hire any other persons for the project.
If they do hire others after receiving the building permit:
- Must notify the office within three (3) working days
- Must provide proof of workers’ compensation coverage
Failure to comply results in a STOP WORK order, which cannot be lifted until proper coverage is obtained.
Legal basis cited:
- Section 302(e)(4) of the Act of June 2, 1915 (P.L. 736)
- Known as The Pennsylvania Workers’ Compensation Act
- Amended on: June 21, 1939; December 5, 1974; July 2, 1993 (Act 44)
Signature and Date lines are required at the bottom.
Contact Information (from header)
- Address: 401 Blair Street, Hollidaysburg, PA 16648
- Website: www.hollidaysburgpa.org
- Phone: (814) 696-7543
- Fax: (814) 696-0636
- TTY: (814) 696-0300
Notes
- No document date is visible — so “none” is used per instructions.
- This form is likely submitted with a building permit application to ensure legal compliance with state labor laws.
- Designed for clarity and enforceability — includes legal citations and consequences for noncompliance.