Independent Contractor Waiver of Workers’ Compensation ...
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Independent Contractor Waiver of Workers' Compensation Coverage
I
(Name of Contractor)
am an independent contractor, with no
employees, no casual laborers, and no sub-contractors performing work for
.
(Name of Employer)
I am not the employee of
(Name of Employer)
for workers'
compensation purposes, and therefore, I am not entitled to workers' compensation benefits
under their policy coverage. I waive any and all rights to file any claims against said employer in
the event an accident should occur while I am performing work on their premises for the period
of
until
.
Signed:
(Name of Contractor)
Date:
................
................
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