(11)_Workers_Compensation_Exemption_Declaration_Construction_(1).pdf
PDF 86 KB Posted
- Attached to
- Hazardous Waste Removal Services
- Solicitation number
- HAZ2604A
- Issued by
- Los Angeles County, San Francisco City, California
About this file
This is a Workers' Compensation Exemption Declaration form required by the William S. Hart Union High School District in California for contractors bidding on the Hazardous Waste Removal Services contract (Package HAZ2604A). The form serves as a certification that contractors either maintain required workers' compensation insurance coverage or qualify for an exemption based on having no employees. Contractors must acknowledge their understanding of California Labor Code Sections 3700, 3700.5, 3710.1, and 3710.2, which mandate that all employers carry workers' compensation insurance or obtain a certificate of self-insurance from the California Department of Industrial Relations. The form requires contractor signature and certification under penalty of perjury that the business is in compliance with California workers' compensation laws. Contractors must initial multiple acknowledgment sections confirming awareness of potential criminal penalties, including fines up to $10,000 and imprisonment, as well as stop orders issued by the Director of Industrial Relations for non-compliance. The District reserves the right to notify state agencies and suspend or revoke operating permits if evidence surfaces contradicting the declaration.
The exemption declaration applies specifically to contractors with no employees and requires submission of the completed and signed form as part of bid submission for the three-year hazardous waste removal services contract commencing July 1, 2026. Contractors who subsequently hire employees must immediately notify the District and provide a certified workers' compensation insurance certificate. The form also requires contractors to hold the District harmless for any losses or liabilities arising from failure to comply with California workers' compensation insurance requirements. This documentation is a mandatory compliance requirement for all bidders, regardless of their current employee status, and forms part of the District's due diligence to ensure all contractors meet state regulatory obligations.
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Text version
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: ____________________________________________________________________________
| LEGAL OR DBA NAME: |
| TIN: |
| Contractor Name: |
| Print Name of Applicant: |
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