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Workers Compensation Information Form

Workers Compensation Information Form 2026

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The document is a Workers’ Compensation Information Form that includes an affidavit of exemption for property owners and contractors in Pennsylvania. It outlines conditions under which individuals are not required to provide workers' compensation insurance, such as performing their own work, having no employees, or claiming a religious exemption. The form must be notarized and includes spaces for signatures and municipal information.

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Click ‘Get Form’ to open the Workers Compensation Information Form in the editor.
Begin by reviewing the affidavit section. Indicate your reason for exemption by checking the appropriate box, such as if you are a property owner performing your own work or if your contractor has no employees.
If applicable, attach copies of any religious exemption letters for all employees as required under the relevant law.
Fill in your signature in the designated area and provide details about the county and municipality where you are located.
Ensure that you have a notary public present to witness your signature. The notary will need to sign and seal the document, confirming its authenticity.

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Versions	Form popularity	Fillable & printable
2017	4.9 Satisfied (53 Votes)

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What is a c11 form for workers comp?

C-11: Employers Report of Injured Employees Change in Status. Report any change in a claimants work status as soon as it occurs to NYSIF by submitting Form C-11, including return to work, discontinuance of work, decrease in regular working hours or reduction of wages.

Where to send form 5020?

Forward the original copy of the Form 5020, the accident investigation forms and the completed and signed DWC1 to WCD at 700 East Temple Street, Room 210, Los Angeles, CA 90012, Mail Stop 391, by fax at (213) 473-3333, or via email at per.wcdiv@lacity.org.

What is a 5021 form?

Electronic Reporting System for Doctors First Report of Injury. Every physician who treats an injured employee must file a complete Form 5021 Doctors First Report of Occupational Illness or Injury (DFR) with the employers claims administrator within five days of the initial examination.

What is a 5020 form for workers compensation?

The Employers Report of Occupational Injury or Illness (Form 5020). Every employer is required to file a complete report of every occupational injury or illness to each employee which results in lost time beyond the date of injury or illness or which requires medical treatment beyond first aid*.

How to complete a workers compensation form?

0:26 2:00 This will include your higher date. And your job duties. You will also need to provide your wageMoreThis will include your higher date. And your job duties. You will also need to provide your wage information this typically means your hourly rate or salary.

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