(11)_Workers_Compensation_Exemption_Declaration_Construction_(1).pdf

Declaration Regarding California Workers' Compensation

LEGAL OR DBA NAME: ______________________________________ TIN:_______________________

You are required to complete this form because you have not filed a certificate regarding workers' compensation insurance with the William S. Hart Union High School District (DISTRICT). California law requires all employers to carry workers' compensation insurance, even if they have only one employee. If you are the sole owner and you have no employees, or if your business is an out-of-state corporation with no employees working in California, you may not be required to carry workers' compensation insurance. It is your responsibility to comply with the law. If you do not know whether you are required to carry workers' compensation insurance, find out by contacting the California Department of Industrial Relations ("DRE").

Information is also available on the DRE's website at http://www.dir.ca.gov. If you are subject to the Workers’ Compensation

Laws of California, you must promptly file a certificate of Workers’ Compensation Insurance with the DISTRICT. If you have a certificate of self-insurance from the DRE, you must file that certificate with the DISTRICT. When completing this form, remember that the term “employee” includes clerical persons as well as any other persons employed by your company including drivers.

ACKNOWLEDGEMENT

___ (Initial) California Labor Code § 3700 requires employers to carry workers' compensation insurance or to obtain a certificate from the Director of Industrial Relations demonstrating that the employer is self-insured. California Labor Code §

3700.5 makes it a criminal offense for an employer to fail to secure compensation as required by the workers'' compensation provisions of the Labor Code. Violation of Labor Code § 3700 is punishable by a fine of up to $10,000 and/or imprisonment for up to one year.

___ (Initial) California Labor Code § 3710.1 provides that where an employer fails to provide compensation required under§

3700, the Director of the Department of Industrial Relations shall issue a stop order, prohibiting the employer from using employee labor until such time as the employer complies with the provisions of § 3700. Labor Code § 3710.2 makes it a criminal offense to disregard such stop orders.

___ (Initial) I acknowledge that if evidence is found that contradicts this declaration, the DISTRICT will promptly notify all relevant state agencies to ensure full insurance compliance required by Workers’ Compensation Laws of California and that my operating permit will be suspended and/or revoked.

DECLARATION REGARDING WORKERS' COMPENSATION COVERAGE

___ (Initial) I understand that California Labor Code §§ 3700 et seq requires employers to provide worker’s compensation insurance coverage for any employees of my business. I hereby warrant that this business is exempt from the California

Labor Code provisions regarding workers compensation insurance because it has no employees.

___ (Initial) I agree to hold the DISTRICT harmless for loss or liability which may arise from the failure of the above-mentioned business to comply with the laws of the State of California regarding workers' compensation insurance.

___ (Initial) If I hire employees in the future, I will immediately notify the DISTRICT and provide a certified Workers’

Compensation certificate.

CERTIFICATION

I (we) certify (or declare) under penalty of perjury that I (we) have read and understood the above stated requirements regarding Workers’ Compensation and that I (we) am (are) in compliance. I (we) certify (or declare) that the forgoing is true and correct.

Contractor Name: _______________________________________________________________________________

Print Name of Applicant: __________________________________________________________________________

Signature of Applicant: ____________________________________________________________________________