Affidavit_Regarding_Workers'_Compensation.pdf
PDF 129 KB Posted
- Attached to
- City Center Sport Complex Ballfields Restoration
- Solicitation number
- ITB-26-22-CW
- Issued by
- Volusia County, Florida
About this file
This is an Affidavit Regarding Workers' Compensation form required by the City of Port Orange, Florida for awarded bidders on the City Center Sport Complex Ballfields Restoration project. The affidavit must be completed and returned by the awarded bidder upon issuance of a Notice of Intent to Award by the Purchasing Division. The form documents the contractor's acceptance of Florida's Workers' Compensation laws and confirms that the contractor has secured workers' compensation insurance coverage through an authorized carrier for a specified policy period.
The City of Port Orange does not accept exemptions from Workers' Compensation coverage. The affidavit requires the contractor to identify the insurance carrier, policy number, and coverage dates, and must be notarized by a Florida notary public. Completion of this form is mandatory for all awarded proposers before they can proceed with the contract for the ballfields restoration project, which involves excavation, soil removal, identification and disposal of landfill materials, geotextile membrane installation, fill replacement, and reconstruction of ballfields and associated site improvements.
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Text version
This affidavit must be completed and returned by the Awarded Bidder upon issuance of a Notice of Intent to Award by the Purchasing Division of the City of Port Orange. Please note, the City of Port Orange does not accept exemptions for Workers’ Compensation coverage.
AFFIDAVIT REGARDING WORKERS’ COMPENSATION
State of ____________________________________
County of _________________________________
I, __________________________________________________________, being duly sworn according to law, deposes and says (it, he, she, they) have accepted the Workers’ Compensation laws of the State of Florida, with its supplements and amendments and has insured (its, his, her, their) liability there under accordance with the terms of said Laws with the ____________________________________________________ Company, under the terms of Policy Number _____________________ for a period from _______________________, 20_____ to ________________________, 20_____.
WITNESS: CONTRACTOR:
By:________________________________________________ Company:______________________________________________
Name:_____________________________________________ By:______________________________________________________
Name/Title: ___________________________________________
Sworn to/Affirmed and subscribed before me this ________________ day of _______________________, 20_____, by
_______________________________________, who is personally known to me or who produced
_______________________________________________________ as identification.
NOTARY PUBLIC – STATE OF
Type or Print Name:________________________________
Commission No.: ___________________________________
Commission Expires:_______________________________
(Seal)
IMPORTANT: This certificate must be completed and returned by the Awarded Proposer upon issuance of a Notice of Intent to Award by the Purchasing Department of the City of Port Orange.
File details come from the government source that posted it. Updated .