Affidavit Of Exemption From Kentucky Workers Compensation Act (Corporation Or Partnership)
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Affidavit Of Exemption From Kentucky Workers Compensation Act (Corporation Or Partnership) Form. This is a Kentucky form and can be use in Workers Comp.
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Adopted 1/1/97
AFFIDAVIT OF EXEMPTION FROM THE
KENTUCKY WORKERS’ COMPENSATION ACT
(Corporation or Partnership)
Applicant, pursuant to KRS 342. 610 (5), hereby declares exemption from the requirement to
obtain workers’ compensation insurance coverage as set forth in KRS 342.340. In support of
this claim to exemption, Applicant states that the following facts are true and correct:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Full name of Applicant ____________________________________________________
Business address _______________________________ Phone No. _________________
_______________________________________________________________________
Nature of Business _______________________________________________________
FEIN or SSN ______________________ Average No. of Employees________________
The foregoing is true and correct as I verily believe and swear.
__________________________________________
Applicant/or authorized agent
State of Kentucky Labor Cabinet
County of _______________________
The foregoing Affidavit of Exemption was acknowledged and sworn to before me
by _________________________ of ____________________________________ on
Corporation/Partnership
behalf of the, _____________________________ this ______ day of __________, 20___.
Corporation/Partnership
__________________________________________
NOTARY PUBLIC
KENTUCKY STATE AT LARGE
MY COMMISSION EXPIRES_______________, 20___.
Instructions
This original Affidavit is to be immediately filed by the local building permit office with the Kentucky Department
of Workers’ Claims, Division of Security & Compliance, 657 Chamberlin Ave., Frankfort, KY 40601 (1-800-5548601).
A copy of this Affidavit is to be kept on file with the local office, which issues the building permit.
Notice of Affiant: Fraudulent execution of this form constitutes a criminal offense (KRS 523.030), under the laws
of the Commonwealth.
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