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Please ﬁll out the workers’ compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply your insurance company’s name, address, and phone number along with a certiﬁcate of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers’ compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers’ compensation policy, please call the
Department. Self-insured companies should enter their self-insurance license number on the appropriate line.
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