14-Workers Comp Affidavit.pdf
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- Attached to
- 2026 Road Paving Program
- Solicitation number
- Not on record
- Issued by
- Chester County, Pennsylvania
About this file
This is a Worker's Compensation Affidavit form required by West Whiteland Township, Pennsylvania for the 2026 Road Paving Program. The affidavit certifies that contractors have accepted the provisions of Pennsylvania's Worker's Compensation Act of 1915 and have obtained appropriate insurance coverage. The form requires the contractor to identify the insurance company providing coverage and be signed by an authorized representative. The document serves as proof of compliance with state worker's compensation requirements prior to bid submission or contract award.
The affidavit is a mandatory compliance document for contractors bidding on the 2026 Road Paving Program, which involves milling and paving of approximately 19,500 square yards across six roads in West Whiteland Township. Sealed bids are due June 18, 2026, at 1:00 pm via PennBid, with prevailing wage requirements in effect. Liquidated damages of $885.00 per calendar day apply for work incomplete after September 30, 2026. The municipality reserves the right to reject any or all proposals. This worker's compensation documentation is a prerequisite requirement that must be completed and submitted as part of the bidding process.
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Text version
101 Commerce Drive Tel: (610) 363–9525 Exton, Pennsylvania 19341 www.westwhiteland.org
Worker’s Compensation Affidavit
State of ) §
County of )
_________________________________ being duly sworn according to law deposes and says that (he has)(they have)(it has) accepted the provisions of the Worker’s Compensation Act of 1915 of the
Commonwealth of Pennsylvania, with it supplements and amendments, and (has)(have) insured
(his)(their)(its) liability thereunder in accordance with the terms of said Act with
(INSURANCE COMPANY)
CONTRACTOR (TYPE OR PRINT)
BY __________________________________________________
NAME (TYPE OR PRINT) SIGNATURE
Sworn to and subscribed to me this ______ day of ____________________ A.D. 20_____
My Commission Expires_____________________
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