Insurance Waiver of Worker's Comp

INSURANCE WAIVER OF WORKER'S COMP

Applicant / Insured Information

Date of Birth:    Phone:

Employment / Contractor Information

Employer Address:

Employment Status (select all that apply):

Employee    Independent Contractor    Sole Proprietor    Volunteer

Policy / Coverage Details

Policy Number:    Policy Type:

Coverage Amount: $    Deductible: $    Premium: $

Policy Period From:    To:

Coverage Election / Waiver

The undersigned elects (select one):

To DECLINE any employer-provided workers' compensation coverage and to waive rights to claim workers' compensation benefits from the employer for services performed for the period indicated above.

To MAINTAIN my own accident or liability insurance covering injuries or occupational illnesses arising from the performance of services and to provide proof of coverage to the hiring entity upon request.

Acknowledge that I am NOT covered under any workers' compensation policy maintained by the hiring entity for the work described in this waiver.

Certificate of Insurance    Policy Declarations Page    Proof of Premium Payment

Exclusions & Limitations

The applicant acknowledges that the following categories are excluded from this waiver or require separate agreement (check all that apply if understood):

Occupational disease claims where law mandates coverage    Claims by subcontractors where a separate indemnity exists

Any statutory obligations that cannot be waived by law

Beneficiary Designation (Optional)

Designate one or more beneficiaries to receive any eligible proceeds or death benefits arising under any personal policy the applicant maintains.

Relationship:    Percentage:

Acknowledgment, Release, and Indemnity

By signing below, the undersigned certifies that all information provided on this form is true and complete to the best of my knowledge. I expressly acknowledge and agree that:

1. I voluntarily waive any claim for workers' compensation benefits against the hiring entity for injuries, illnesses, or death arising from the performance of the services described herein where such waiver is permitted by applicable law.

2. I assume all risks associated with the performance of the services and agree to indemnify, defend, and hold harmless the hiring entity, its officers, agents, employees, and affiliates from and against any and all claims, liabilities, losses, costs, and expenses (including reasonable attorney fees) arising out of my acts or omissions, except to the extent caused by the hiring entity's gross negligence or willful misconduct.

3. I understand that this waiver does not create an employment relationship if none otherwise exists. I acknowledge that I have had the opportunity to seek independent legal advice prior to executing this waiver and that I am executing this instrument knowingly and voluntarily.

4. To the extent any statutory or regulatory requirement precludes waiver of certain rights, this document shall be construed consistent with such requirement and shall be severable as to any provision held unenforceable.

Certification and Signature

I certify under penalty of perjury that the statements made in this waiver are true and correct and that I have authority to execute this waiver. I further certify that I have read and understand the contents of this document, including the release and indemnity provisions.

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