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AFFIDAVIT OF WORKERS COMPENSATION COVERAGE N.C.G.S. 8714 The undersigned applicant for Building Permit # being the Contractor Owner Officer/Agent of the Contractor or Owner do hereby aver under penalties
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How to fill out affidavit of workers compensation

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To fill out an affidavit of workers compensation, follow these steps:

01
Start by obtaining the necessary form. You can typically obtain this form from your employer or the relevant workers compensation agency.
02
Read the instructions carefully. It's important to understand the requirements and provide accurate information.
03
Begin by entering your personal information, such as your name, address, and contact details. Make sure to double-check the accuracy of your information.
04
Provide details about your employment, including your job title, start date, and any relevant job-related injuries or incidents that relate to your workers compensation claim.
05
If you have received medical treatment for your work-related injury, include information about the healthcare provider, dates of treatment, and any medical records or documentation.
06
Indicate whether you have previously filed a workers compensation claim for the same injury. If so, provide details about the previous claim, including the date filed and any outcomes or settlements.
07
If there were any witnesses to the work-related incident, provide their names and contact information. Witnesses can play a vital role in supporting your claim.
08
Sign and date the affidavit, attesting that the information provided is true and accurate to the best of your knowledge.
09
Keep a copy of the completed affidavit for your records.
Anyone who has suffered a work-related injury or illness and intends to file a workers compensation claim may need to complete an affidavit of workers compensation. This document helps provide detailed information about the incident, injuries, and medical treatment to support the claim. It is typically required by the workers compensation agency or your employer's insurance provider.
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Affidavit of workers compensation is a legal document signed by an employer certifying compliance with workers compensation laws.
Employers are required to file affidavit of workers compensation.
To fill out affidavit of workers compensation, employer must provide accurate information regarding their workers compensation insurance coverage.
The purpose of affidavit of workers compensation is to ensure employers have proper insurance coverage for their employees in case of work-related injuries.
Information such as the name of the insurance provider, policy number, and effective dates of coverage must be reported on affidavit of workers compensation.
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