FORM “D”
WAIVER AND RELEASE
HOLD HARMLESS
BUSINESS LIABILITY INSURANCE
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:
AGREEMENT TO AFFIRM
INDEPENDENT CONTRACTOR RELATIONSHIP
FOR THE PURPOSE OF
BUSINESS OPERATIONS LIABILITY INSURANCE
The undersigned HIRING CONTRACTOR and/or GENERAL CONTRACTOR and the undersigned INDEPENDENT CONTRACTOR hereby declare and agree that the INDEPENDENT CONTRACTOR will purchase liability insurance equal to at least $50,000 Bodily Injury and $25,000 Property Damage. The INDEPENDENT CONTRACTOR AGREES to ADD the HIRING CONTRACTOR AND/OR GENERAL CONTRACTOR as an ADDITIONAL INSURED to the INDEPENDENT SUB-CONTRACTOR’S BUSINESS LIABILITY INSURANCE. The INDEPENDENT SUB-CONTRACTOR agrees to Waive and Release the HIRING CONTRACTOR and/or GENERAL CONTRACTOR from any and all claims or law suits which may be the sole and independent cause of the INDEPENDENT SUB-CONTRACTOR or INDEPENDENT SUB-CONTRACTOR’S EMPLOYEE’S and to HOLD HARMLESS AND INDEMNIFY THE HIRING CONTRACTOR AND/OR GENERAL CONTRACTOR (OR ITS INSURER) from any claims or law suits which may be the sole and independent cause of the INDEPENDENT SUB-CONTRACTOR or INDEPENDENT CONTRACTOR’S EMPLOYEES.
__________________________________
Name of GENERAL CONTRACTOR (if any)
_____________________________________ ________________________________________
Name of HIRING CONTRACTOR Name of INDEPENDENT SUBCONTRACTOR
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 BUSINESS LIABILITY 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 CLAIM COSTS 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.