Summary

This is a certification statement form for individual contractors or sole proprietorships seeking exemption from California Workers' Compensation Insurance requirements in connection with a Request for Proposal (RFP). The document serves as an attestation that the bidder does not employ any persons in a manner that would subject the business to California Workers' Compensation Laws. The form requires the contractor to certify under penalty of perjury that no employees are engaged and to commit to notifying the Department of Rehabilitation within ninety (90) days if the business status changes and becomes subject to Workers' Compensation requirements. The form includes blank fields for the RFP number, contractor's printed name, signature, and date of certification.

No pricing, set-asides, incumbents, funding sources, or other contract-specific terms are addressed in this document, as it is solely a compliance certification form designed to establish the exempt status of individual or sole proprietorship bidders on state and local contract opportunities.