21-Workers Comp Affidavit.pdf

This is a Worker's Compensation Affidavit form issued by West Whiteland Township, Chester County, Pennsylvania, for the 2026 Traffic Signal Upgrades project. The affidavit requires contractors to confirm acceptance of the Pennsylvania Worker's Compensation Act of 1915 and its amendments, and to certify that they have insured their liability under the act with an appropriate insurance company. The form includes designated spaces for the contractor to provide the name of their insurance carrier, provide their business name and representative signature, and include the date of execution and notary commission expiration. This documentation is a mandatory compliance requirement for all bidders participating in the traffic signal upgrades project along Pottstown Pike (S.R. 0100) and Commerce Drive within West Whiteland Township.

The affidavit serves as proof of workers' compensation coverage, which is a standard prerequisite for contract award in Pennsylvania public works projects. All contractors submitting proposals for the traffic signal upgrades—with sealed bids due by December 1, 2026—must provide this sworn affidavit as part of their proposal package. Failure to demonstrate proper workers' compensation insurance coverage may result in bid rejection or disqualification from the project.