Affidavit_Regarding_Workers'_Compensation.pdf
PDF 129 KB Posted
- Solicitation number
- ITB-26-18-CW
- Issued by
- Volusia County, Florida
About this file
This is an affidavit form required by the City of Port Orange, Florida, for contractors awarded on state and local contract opportunities. The document must be completed and submitted by the awarded bidder upon issuance of a Notice of Intent to Award by the City's Purchasing Division. The affidavit pertains to the Mitigation Reconstruction of a Flood Prone Home Project, which involves the installation of a new elevated manufactured home located in a Port Orange manufactured home park community. The contractor must complete the affidavit, have it notarized, and return it as a condition of award acceptance.
The affidavit requires the awarded contractor to certify compliance with Florida's Workers' Compensation laws and provide proof of workers' compensation insurance coverage. The contractor must name the insurance company, provide the policy number, and specify the coverage period. The City of Port Orange does not accept exemptions for Workers' Compensation coverage, making this certification mandatory for all awarded bidders. The document must be sworn before a notary public and include the notary's commission information and seal. Failure to complete and return this affidavit by the awarded proposer will result in non-compliance with the contract award requirements.
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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 .