FORM “C”
WAIVER AND 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
GENERAL CONTRACTOR
AND
SUB-CONTRACTOR
INDEPENDENT RELATIONSHIP AGREEMENT
NOTICE OF AGREEMENT
The undersigned GENERAL CONTRACTOR and the undersigned SUB-CONTRACTOR hereby declare and agree that:
A. The SUB-CONTRACTOR meets the qualifications of an INDEPENDENT CONTRACTOR UNDER STANDARD ACCEPTABLE DEFINITIONS;
B. The SUB-CONTRACTOR is operating as an INDEPENDENT CONTRACTOR AS THAT TERM IS DEFINED UNDER CURRENT GENERAL STANDARDS BY THE FEDERAL GOVERNMENT OR BY THE LAWS IN THE STATE WHERE THIS AGREEMENT IS INTENDED TO APPLY, AND AS DEFINED ABOVE;
C. The SUB-CONTRACTOR assumes the responsibility, and agrees to hold harmless and indemnify the General Contractor as Hiring Contractor, for the performance and work of all employees or sub-contractors; and,
D. The SUB-CONTRACTOR and the SUB-CONTRACTOR’S EMPLOYEES are not employees of the General Contractor as the Hiring Contractor.
Term (DATES) of Agreement: From ___________________________
To: ___________________________
LOCATION OF EACH AFFECTED JOB SITE, OR STATE IF A BLANKET ALL JOB SITE AGREEMENT.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Estimated number of employees effected #_______________________
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 GENERAL CONTRACTOR AS 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.