Workers' Compensation Coverage Waiver

WORKERS' COMPENSATION COVERAGE WAIVER

Employer Name:    Employer DBA:

Applicant / Insured Information

Date of Birth:

Individual    Sole Proprietor    Partnership    Corporation    LLC    Other:

Engagement / Policy Details

Engagement Start Date:

Estimated Engagement End Date (if any):

Are you currently covered by any workers' compensation or employer liability insurance? Yes No

Waiver and Release

Effective Date of Waiver:

The undersigned Applicant, in consideration of engagement by the Employer named above, hereby acknowledges and agrees as follows:

1. Representation of Status. The Applicant represents that the Applicant performs services as an independent contractor or is otherwise an owner/operator or person whose employment classification does not require the Employer to obtain workers' compensation coverage under applicable law. Applicant affirms that such classification is accurate and complete for the period of this waiver.

2. Waiver of Employer Coverage. To the maximum extent permitted by applicable law, the Applicant knowingly and voluntarily waives any right to workers' compensation benefits or employer-funded medical or wage-loss benefits from the Employer for any injury, occupational disease, or death arising out of or in the course of performing the described services during the Effective Date of Waiver. Applicant understands that this waiver is specific to the relationship with the Employer and does not affect rights under other coverage arranged by the Applicant.

3. Assumption of Responsibility and Indemnity. The Applicant agrees to assume responsibility for obtaining and maintaining any personal medical, disability, or liability insurance deemed necessary by the Applicant. The Applicant shall defend, indemnify, and hold harmless the Employer, its officers, directors, employees, and agents from and against any claims, liabilities, losses, damages, costs, and expenses (including reasonable attorneys' fees) arising from or related to personal injury, occupational illness, or death claimed by or on behalf of the Applicant, except to the extent caused by the Employer's gross negligence or intentional misconduct.

4. Limitations and Legal Compliance. This Waiver is intended to be interpreted in accordance with applicable state and federal law. Nothing in this Waiver shall be construed to waive rights that cannot be waived as a matter of law. If any provision of this Waiver is determined to be unenforceable under applicable law, that provision will be severed and the remainder of this Waiver will remain in full force and effect.

Exclusions and Special Conditions

The waiver expressly excludes claims arising from Employer's intentional torts and does not apply to any statutory benefits or protections that the Applicant is entitled to under law notwithstanding any private agreement. Applicant further acknowledges that this Waiver does not modify or limit the Employer's obligations under any other mandatory statutory insurance for which waiver is not permitted.

Notices

Certification

By checking the box below and signing, the Applicant certifies under penalty of perjury that the statements in this Waiver are true and correct to the best of the Applicant's knowledge and that the Applicant has the authority and legal capacity to execute this Waiver. The Applicant further acknowledges that the Applicant has read this Waiver in its entirety, received a copy, and had the opportunity to consult with legal counsel prior to signing.

I certify that the foregoing is true and correct and that I have authority to execute this Waiver.

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