Affidavit_Regarding_Workers'_Compensation.pdf

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.