NOTE: The below described “Insurance Waiver Form” is ...
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SAMPLE AUTOMOBILE AND/OR WORKERS’ COMPENSATION INSURANCE
WAIVER REQUEST LETTER
Last Updated: 7/22/2008
PLEASE PRINT LETTER ON ORGANIZATION LETTERHEAD
[Date]
[Name of SBS Contract Manager]
New York City Department of Small Business Services
110 William Street, 7th Floor
New York, NY 10038
Re: Insurance Waiver Request for Agreement No. [SBS Contract Number]
Dear [Name of SBS Contract Manager]:
This is to advise you that [name of organization] does not own or plan to own, operate or lease any automotive vehicle during the term of the above described agreement with the New York City Department of Small Business Services.
[and/or]
[Name of organization] has no paid employees performing the services outlined in the contract with the New York City Department of Small Business Services and does not pay Workers’ Compensation Insurance.
[Name of organization] is therefore requesting a waiver of those provisions relating to the automobile insurance coverage [and/or] Workers’ Compensation Insurance.
Thank you for your assistance in this matter.
Sincerely,
[Name and Title]
................
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