Employers Certificate Of Insurance {LIBC-661}

LIBC-661 - EMPLOYER’S CERTIFICATE OF INSURANCE. This form is used by businesses in Pennsylvania to demonstrate compliance with Section 305 of the Pennsylvania Workers’ Compensation Act. It requires employers to provide details confirming they either have valid workers’ compensation insurance or are legally exempt. Employers must include the number of Pennsylvania employees, their business and insurance details, and, if insured, information about their policy and insurance agent. If the business does not carry insurance, it must indicate the reason, such as being out of business, having zero employees, or qualifying for specific exemptions. The form must be signed by an authorized representative of the business and submitted to the Pennsylvania Department of Labor & Industry’s Bureau of Workers’ Compensation. Filing false information can lead to criminal and civil penalties under state law. www.FormsWorkflow.com