AFFIDAVIT OF EXEMPTION FROM THE WORKERS' COMPENSATION ACT The

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posted:: 1/3/2010
language:: English
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Document Sample

							                                   AFFIDAVIT OF EXEMPTION
                                         FROM THE
                                 WORKERS’ COMPENSATION ACT

         The Affiant, ________________________________________, being duly sworn states that

_______________________________________________, is exempt from the provisions of the
            NAME OF BUSINESS

Kentucky Workers’ Compensation Act, KRS Chapter 342. Affiant states that the form of

Business is:

                Individual Proprietorship

                Corporation

                Partnership, the names of the partners are ______________________________

               ______________________________________________________,

Affiant states that _________________________________________________________, has
                                         NAME OF THE BUSINESS

no employees. Affiant states that __________________________________________________
                                          NAME OF THE BUSINESS

will employee no subcontractors with employees without first obtaining a policy of workers’

compensation insurance. The Affiant affirms that should this status change prior to renewal of the

contractors license, that the Affiant will advise the Bowling Green-Warren County Contractors Licensing

Board.

         The Affiant further states that any contractors, subcontractors, or employees shall be in

Compliance with Kentucky requirements for Workers’ Compensation insurance according to KRS Chapter

342.

         This the ________ day of _____________________, 2008.

                                             _____________________________________________
                                             AFFIANT

STATE OF KENTUCKY
COUNTY OF WARREN

         Subscribed and sworn to before me by ________________________________________

This ________ day of ___________________________, 2008.

                                             _____________________________________
                                             NOTARY PUBLIC
                                             My Commission Expires: ________________

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