NOTICE REGARDING

WORKERS COMPENSATION COVERAGE

It is imperative that (name of contractor)
____________________________________________ keeps on file a copy of
Certificates of Insurance showing Workers Compensation coverage for all
contractors.
Alternatively, if you are a Sole Proprietor of Subcontractor without
employees, the following information will be acceptable in lieu of a
Certificate. However, all information must be completed and reviewed for
validation.
NAME OF SUBCONTRACTOR/SOLE PROPRIETER:
______________________________________________________________________________
ADDRESS:
_____________________________________________________________________
PHONE: __________________________________
SOCIAL SECURITY NUMBER or
FEDERAL IDENTIFICATION NUMBER: _______________________________
(If applicable, please attach a copy of the assumed name that you have filed with the
county.)

PLEASE COMPLETE THE FOLLOWING STATEMENT:

I, _________________________________________________am sole proprietor and
waive my coverage of workers compensation:
I do not have employees, and I will not be using any employees during
the execution of my work on property owned or controlled by
___________________________________
(Initial prior to the start of contract work.)

Or
I do not have employees, and I have not had any employees for the
duration of me work on property owned or controlled by
__________________________________________
(Initial after completion of contract work.)

____________________________
Date

______________________________
Signature