FORM “A”
WAIVER & RELEASE
WORKERS COMPENSATION
LIABILITY
FIRST: If you are not certain whether all parties to this agreement meet the requirements for entering into this contract, you may wish to consult with an attorney.
SECOND: “Independent Contractor” is generally defined as follows: “INDEPENDENT CONTRACTOR” means a person who contracts to perform work or provide a service for a benefit of another and who; {A} is paid by the job, not by the hour or some other time-measured basis; {B} is free to hire as many helpers as he desires and to determine what each helper will be paid; and {C} is free to work for other contractors, or to send helpers to work for other contractors, while under contract to the hiring contractor.
THIRD: Formal Agreement:
JOINT AGREEMENT TO AFFIRM
INDEPENDENT RELATIONSHIP
FOR CERTAIN CONTRACTED WORKERS
The undersigned HIRING CONTRACTOR and the undersigned INDEPENDENT CONTRACTOR hereby declares that the INDEPENDENT CONTRACTOR meets the qualifications of an INDEPENDENT CONTRACTOR and that the INDEPENDENT CONTRACTOR AND HIS EMPLOYEES are not employees of the HIRING CONTRACTOR, and that:
A. The INDEPENDENT CONTRACTOR and the INDEPENDENT CONTRACTOR’S EMPLOYEE’S shall not be entitled to workers compensation insurance or coverage from the HIRING CONTRACTOR; and,
B. The HIRING CONTRACTOR’S workers compensation insurance carrier shall not require premiums to be paid by the HIRING CONTRACTOR for coverage of the INDEPENDENT CONTRACTOR or the INDEPENDENT CONTRACTOR’S EMPLOYEE’S, helpers, or sub-contractors.
THIS DECLARATION AND AGREEMENT SHALL APPLY TO ALL HIRING AGREEMENTS EXECUTED BY THE HIRING CONTRACTOR AND THE INDEPENDENT CONTRACTOR DURING THE PERIOD AFTER THIS DECLARATION AND AGREEMENT IS SIGNED. ONCE THIS CONTRACT IS SIGNED, THE SUB-CONTRACTOR AND THE SUB-CONTRACTOR’S EMPLOYEES SHALL NOT BE ENTITLED TO WORKERS COMPENSATION COVERAGE FROM THE HIRING CONTRACTOR.
HIRING CONTRACTORS AFFIRMATION
_____________________________
FEDERAL TAX ID NUMBER
__________________________________ _________ ________________________________
Signature of Hiring Contractor Date Address (street)
_________________________________________ _____________________________________
PRINTED Name of Hiring Contractor Address (City, State, Zip)
_________________________ _________________________ ________________________
Phone FAX E-Mail
INDEPENDENT CONTRACTORS AFFIRMATION
__________________________
FEDERAL TAX ID NUMBER
________________________________ _________ _____________________________
Signature of Independent Contractor Date Address (street)
_________________________________________ _____________________________________
PRINTED Name of Independent Contractor Address (City, State, Zip)
_________________________ __________________________ _______________________
Phone FAX E-Mail
BOTH THE HIRING CONTRACTOR AND THE INDEPENDENT CONTRACTOR MUST RETAIN A COPY OF ANY AGREEMENTS FOR REGULATORY AND INSURANCE PURPOSES.
THE CONTRACTING PARTIES AGREE TO HOLD HARMLESS AND INDEMNIFY ANY INSURANCE PROVIDER FOR CLAIMS AND ANY RELATED CLAIMS COST WHICH MAY BE FILED CONTESTING THIS INDEPENDENT CONTRACT AGREEMENT FOR WHICH IT IS INTENDED TO LIMIT INSURANCE AND COVERAGE TO ONLY THAT WHICH THOSE PARTIES IDENTIFIED AND AGREED AS THE HIRING CONTRACTOR AND INDEPENDENT CONTRACTOR TO WHICH THE INSURERS HAVE NO OTHER DUTY TO DEFEND THAN SPECIFICALLY CONTRACTED HEREIN.