Affidavit of Rejection of Coverage.pdf
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- Attached to
- Direct Client Services
- Solicitation number
- 99SWC-S4027
- Issued by
- Nevada
About this file
This is an Affidavit of Rejection of Industrial Insurance Coverage form issued by the Nevada Department of Administration Risk Management, applicable to sole proprietor vendors contracting with the State of Nevada or its political subdivisions. The form permits qualified sole proprietors to formally reject the State's workers' compensation and industrial insurance coverage requirements under Nevada Revised Statutes (NRS) 616B.627, 616A.310, 617.210, and 617.145. By executing this affidavit, a sole proprietor affirms that they will perform contract work without utilizing employees, subcontractors, or independent contractors, and that they have reviewed relevant Nevada statutes and understand the implications of waiving coverage.
The affidavit requires the vendor to acknowledge and initial nine separate paragraphs confirming their understanding and acceptance of specific conditions, including waiver of workers' compensation benefits, assumption of all medical and disability costs resulting from workplace injuries or occupational diseases, exemption of the State from employer liability, and compliance with applicable Nevada law. Vendors must attest under penalty of perjury that they have had full opportunity to consult with legal counsel and fully understand their liabilities. The form must be notarized and is effective as of April 28, 2026. For assistance, vendors are directed to contact Risk Management at (775) 687-1750.
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Text version
This form is to be used if the awarded vendor is a sole proprietor and rejects the State’s requirement of
Workers Compensation.
Contact Risk Management for assistance at (775) 687-1750.
RM-ARIIC (04/28/2026) 1 of 3 S > RM > Forms > 2026+
DEPARTMENT OF ADMINISTRATION
RISK MANAGEMENT
AFFIDAVIT OF REJECTION OF INDUSTRIAL INSURANCE COVERAGE
STATE OF )
) ss.
_______ COUNTY )
I, _________________________, being first duly sworn, depose and state as follows under penalty of perjury, and by my initials on each paragraph, I certify that I have read and understand each paragraph.
1. I make this affidavit for the purpose of rejecting industrial insurance coverage, pursuant to NRS
616B.627 and NRS 617.210, in connection with entering into a Contract with the State of Nevada or political subdivision of the State of Nevada. After reviewing those statutes and the definitions of “sole proprietor” in NRS 616A.310 and NRS 617.145, I believe I qualify to reject industrial insurance coverage, and I covenant that I will not knowingly do anything that would disqualify me from rejecting industrial insurance under those statutes, without first withdrawing this Affidavit of Rejection and obtaining all statutorily required industrial insurance coverage. ____
2. I am a sole proprietor, as defined by NRS 616A.310 and NRS 617.145, who will not use the services of any employees, subcontractors, or independent contractors in the performance of this Contract with the State of Nevada. _____
3. In accordance with the provisions of NRS 616B.659, I have elected to reject the industrial insurance terms, conditions, and provisions of NRS Chapters 616A to 616D inclusive. By doing so I acknowledge that if I incur an industrial injury or occupational disease in the performance of this Contract that I waive and will be disqualified to receive any workers’ compensation coverage pursuant to Nevada law or the laws of any other state where I have waived coverage. _____
4. In accordance with the provisions of NRS 617.225, I have elected to reject the workers’ compensation terms, conditions, and the provisions of NRS Chapter 617 as it relates to occupational diseases. By doing so, I acknowledge that if I incur an industrial injury or occupational disease in the performance of this
Contract that I waive and will be disqualified to receive any workers’ compensation or occupational disease benefits pursuant to Nevada law or the laws of any other state where I have waived coverage.
5. I acknowledge that the State of Nevada will not be considered to be my employer or the employer of my employees, subcontractors or independent contractors, if any; and that the State of Nevada is not liable as a principal contractor to me or my employees, subcontractors or independent contractors for any compensation or other damages as a result of an industrial injury or occupational disease incurred
RM-ARIIC (04/28/2026) 2 of 3 S > RM > Forms > 2026+ in the performance of this Contract. _____
6. I acknowledge that by signing this waiver I am not eligible for any workers’ compensation or occupational disease benefits that I may be otherwise eligible, in the performance of this Contract. I acknowledge that should I incur any industrial injury or occupational disease in the performance of this
Contract that I will be responsible for any costs, including medical, disability and rehabilitation benefits that I may incur. _____
7. Prior to executing this affidavit, I have had a full and fair opportunity to answer any questions I may have had regarding industrial insurance or occupational disease benefits and liabilities under Nevada law, including the opportunity to consult with counsel of my choice, and this Waiver is made with full knowledge of any liabilities that may incur. _____
8. I have read the provisions of NRS Chapters 616A to 616D, inclusive, and NRS Chapter 617 and I am otherwise in compliance with the terms, conditions and provisions thereof. _____
9. I, _________________________, do hereby swear under penalty of perjury that the assertions of this affidavit are true. _____
NAME
SUBSCRIBED and SWORN to before me by this day of , 20___
Notary Public, in and for said County and State
RM-ARIIC (04/28/2026) 3 of 3 S > RM > Forms > 2026+
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