5-00 45 26 1 Contractor Compliance with Workers Compensation Law.pdf
PDF 69 KB Posted
- Solicitation number
- 26-0277
- Issued by
- Tarrant County, Texas
About this file
This is a Contractor Compliance with Worker's Compensation Law certification form issued by the City of Fort Worth, Texas for City Project No. 106854, a 24-inch water line construction project. The document requires contractors to certify compliance with Texas Labor Code Section 406.096(a), confirming that they provide worker's compensation insurance coverage for all employees assigned to the project. Contractors must also certify, pursuant to Texas Labor Code Section 406.096(b), that they will provide the City with their subcontractors' certificates of compliance with worker's compensation coverage requirements. The form includes signature lines for the contractor representative and requires notarization by a Texas notary public, with fields for the contractor's company name, address, title, and the date of execution.
This certification document contains no information regarding pricing, set-asides, incumbent contractors, funding sources, or contract terms. It functions solely as a compliance verification mechanism to ensure adherence to mandatory Texas worker's compensation insurance requirements prior to contract award and project commencement on the Comancheria Way 24-inch water line project.
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00 45 26 - 1
CONTRACTOR COMPLIANCE WITH WORKER'S COMPENSATION LAW
CITY OF FORT WORTH Comancheria Way 24” WL STANDARD CONSTRUCTION SPECIFICATION DOCUMENTS City Project No. 106854
Revised April 2, 2014
SECTION 00 45 26 1
CONTRACTOR COMPLIANCE WITH WORKER'S COMPENSATION LAW 2
Pursuant to Texas Labor Code Section 406.096(a), as amended, Contractor certifies that it 4 provides worker’s compensation insurance coverage for all of its employees employed on City 5
Project No. 106854. Contractor further certifies that, pursuant to Texas Labor Code, Section 6
406.096(b), as amended, it will provide to City its subcontractor’s certificates of compliance with 7 worker’s compensation coverage. 8
CONTRACTOR: 10
By: ___________________________________ 12
Company (Please Print) 13
Signature: ______________________________ 15
Address 16
Title: __________________________________ 18
City/State/Zip (Please Print) 19
THE STATE OF TEXAS § 22
COUNTY OF TARRANT § 24
BEFORE ME, the undersigned authority, on this day personally appeared 26
___________________________________, known to me to be the person whose name is 27 subscribed to the foregoing instrument, and acknowledged to me that he/she executed the same as 28 the act and deed of ____________________________________ for the purposes and 29 consideration therein expressed and in the capacity therein stated. 30
GIVEN UNDER MY HAND AND SEAL OF OFFICE this ____________day of 32
_______________________, 20__. 33
__________________________________ 36
Notary Public in and for the State of Texas 37
END OF SECTION 39
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