Fill and Sign the Release of Claims and Assumption of Risks for Future Accidental Injuries or Death by Self Employed Independent Contractor Form

Release of Claims and Assumption of Risks for Future Accidental Injuries or Death by Independent Contractor Working under Potentially H azardous Conditions, Including Working with Caustic Chemicals and Heavy Equipment This agreement made on the _____________________________________ (date) , between ____________________________________ (name of independent contractor) of _____________________________________________________________________ ________________________________________________________________________ (street address, city, county, state, zip code) , referred to herein as Contractor , and ___________________________________________ (name of company) , 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 Company . Whereas, Company is in the business of (describe) ________________________ ___________________________________________________________________; and Whereas, Contractor is a (type of job, i.e., welder) _________________________ who desires to perform work for Company as an independent contractor; and Whereas, Contractor understands that he will be working under potentially h azardous conditions, including working with caustic chemicals and heavy equipment; and Whereas, Contractor understands that Company will not allow him to contract with Company to do such work under such conditions without reading and signing this agreement; 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: The undersigned Contractor hereby releases Company , its agents, officers, servants and employees of and from any and all liability, claims, demands, actions and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the undersigned while working for Company as an independent contractor as described above. The undersigned Contractor is aware of the risks and hazards inherent in working for Company as aforesaid, including the fact that he will be working under potentially h azardous conditions, including working with caustic chemicals and heavy equipment; however, Contractor voluntarily assumes all risks of loss, damage, or injury, including death, that may be sustained by the undersigned while working for Company . This release is binding on the heirs, next of kin, executors, administrators and personal representatives of the undersigned. Witness my signature as of the day and date first above stated. ______________________________ Contractor