Affidavit Of Exemption From Kentucky Workers Compensation Act Corp

AFFIDAVIT OF EXEMPTION FROM THE KENTUCKY WORKERS’ COMPENSATION ACT (CORPORATION OR PARTNERSHIP). This Kentucky Labor Cabinet form allows a corporation or partnership to declare exemption from the requirement to obtain workers’ compensation insurance, as permitted under KRS 342.610(5) and KRS 342.340. The affidavit requires details about the applicant, including business name, address, nature of business, federal EIN or SSN, and average number of employees. It must be signed by an authorized agent and notarized. The original affidavit is filed by the local building permit office with the Kentucky Department of Workers’ Claims, Division of Security & Compliance, while a copy remains on file locally. Fraudulent execution of this affidavit is a criminal offense under KRS 523.030. www.FormsWorkflow.com