Affidavit Of Exemption To Show Specific Proof Of Workers Compensation Insurance Form
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1
2Affidavit of Exemption to Show Specific Proof of Workers’ Compensation Insurance
Coverage for a 1, 2, 3 or 4 Family, Owner-occupied Residence
**This form cannot be used to waive the workers’ compensation rights or obligations of any party.**
Under penalty of perjury
, I certify that I am the owner of the 1, 2, 3 or 4 family, owner-occupied residence
(including condominiums) listed on the building permit that I am applying for, and I am not required to show
specific proof of workers’ compensation insurance coverage for such residence because (please check the
appropriate box):
I am performing all the work for which the building permit was issued.
I am not hiring, paying or compensating in any way, the individual(s) that is(are) performing all the work
for which the building permit was issued or helping me perform such work.
I have a homeowner’s insurance policy that is currently in effect and covers the property listed on the
attached building permit AND am hiring or paying individuals a total of less than 40 hours per week
(aggregate hours for all paid individuals on the jobsite) for which the building permit was issued.
I also agree to either:
♦
acquire appropriate workers’ compensation coverage and provide appropriate proof of that coverage on
forms approved by the Chair of the NYS Workers’ Compensation Board to the government entity issuing
the building permit if I need to hire or pay individuals a total of 40 hours or more per week (aggregate hours
for all paid individuals on the jobsite) for work indicated on the building permit
or if appropriate, file a
,
WC/DB-100 exemption form; OR
♦
have the general contractor, performing the work on the 1, 2, 3 or 4 family, owner-occupied residence
(including condominiums) listed on the building permit that I am applying for, provide appropriate proof of
workers’ compensation coverage or proof of exemption from that coverage on forms approved by the Chair
of the NYS Workers’ Compensation Board to the government entity issuing the building permit if the
project takes a total of 40 hours or more per week (aggregate hours for all paid individuals on the jobsite) for
work indicated on the building permit.
___________________________________
___________________
(Signature of Homeowner)
(Date Signed)
___________________________________
Home Telephone Number ___________________
(Homeowner’s Name Printed)
Property Address that requires the building permit:
__________________________________
__________________________________
__________________________________
__________________________________
Once notarized, this Form BP-1 serves as an exemption for both workers’ compensation and disability benefits
insurance coverage.
BP-1 (9-07
)
NY-WCB
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