Fill and Sign the Employee Workers Compensation Form

Agreement of Employee Service Provider to Maintain Workers' Compensation Insurance Agreement made on the __________________________________ (date) , between _____________________________________________ (Name of Employee Service Provider) , a corporation organized and existing under the laws of the state of _______________________, with its principal office located at ____________________ ________________________________________________________________________ ___________________________ (street address, city, county, state, zip code) , referred to herein as Provider , and __________________________________ (Name of Client) of ________________________________________________________________________ ___________________________________ (street address, city, county, state, zip code) , hereinafter called Client . Whereas, Provider has agreed to provide Client with (type of employee provided such as personal care assistants) ____________________________________________ _______________________________________________________________________; Now, therefore, for and in consideration of the mutual covenants contained in this agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows: Provider shall maintain workers' compensation insurance as required by the law of the state where services will be provided and Provider maintains employees for use by Client. Client shall have no liability for any contributions, taxes or assessments required to be paid or withheld for employees of Provider shall or its subcontractors and third parties under any law or regulation, including but not limited to federal, state or local income, payroll expense, head tax or school board taxes, unemployment compensation, workers' compensation, disability, pension, retirement income security, Medicare, or Social Security. Provider shall indemnify and hold Client harmless from and for any and all liability which may arise for damages, loss or injuries, either to person or property, which any employee of Provider may sustain while on the property of Client at the address listed above. WITNESS our signatures as of the day and date first above stated. ______________________________ _____________________________ Employee Service Provider Customer