Flagler_Hold_Harmless_Agreement_.pdf

HOLD HARMLESS AGREEMENT

I, , (print owner’s name), am the owner of (print company name), an incorporated/unincorporated business operating in the State of Florida. As such, I am bound by all laws of the state of Florida, including but not limited to those regarding the workers’ compensation law.

I hereby affirm that I or [the above-named business] employs fewer than four employees, all of whom are listed below, including myself, and therefore, the business is exempt from the statutory requirement for workers’ compensation insurance for its employees. I certify that I will provide Flagler County Board of County Commissioners with the name of each new employee together with all required waivers and releases for each prior to any employee being allowed to work to provide services under the Contract set forth below. If any such employee is allowed to work without a signed waiver and release, such action will be a material breach of this Agreement. All signed waivers and releases shall be furnished before the commencement of any work by an employee or the undersigned to the County Project Manager or designated county representative.

On , 20 , Flagler County Board of County Commissioners and I or

(the above-named business) entered into a Contract for (please insert name of Contract) (hereinafter “Agreement”) which is incorporated by reference herein.

On behalf of myself, my business, and the employees listed below, I and they hereby agree to waive and release any and all workers’ compensation claims or liens under Chapter 440, Florida Statutes, against Flagler County Board of County Commissioners and its agents, officials and employees, arising from any work or services provided under the Agreement whether or not it shall be alleged or determined that the act was caused by intention, or through negligence or omission of Flagler County Board of County Commissioners or its agents, officials and employees or subcontractors.

In the event that a workers’ compensation claim or lien is made against Flagler County

Board of County Commissioners and/or its agents, officials or employees by myself or my employees or agents as a result of any work or services performed under the Agreement, I agree to indemnify, keep and hold harmless Flagler County Board of County Commissioners, its agents, officials and employees, against all injuries, deaths, losses, damages, claims, liabilities, judgments, costs and expenses, direct, indirect or consequential (including, but not limited to, fees and charges of attorneys and other professionals) arising out of the Agreement with Flagler County Board of County Commissioners, whether or not it shall be alleged or determined that the act was caused by intention or through negligence or omission of Flagler County Board of County Commissioners or its employees, agents, or subcontractors. I or the above-named business shall pay all charges of attorneys, and all costs and other expenses incurred in connection with the indemnity provided herein, and if any judgment shall be rendered against Flagler County Board of County Commissioners in any action indemnified hereby, I or the above-named business shall, at my or its own expense, satisfy and discharge the same. The foregoing is not intended, nor should it be construed as, a waiver of sovereign immunity of Flagler County Board of County Commissioners under Section 768.28, Florida Statutes.

Owner: (print name)

(signature)

Employee 1:

(print name)

Employee 2:

Employee 3:

STATE OF

COUNTY OF

Sworn to and subscribed before me t h i s day of , 20 , by

, who is/are personally known to me o r who has/have produced as identification.

NOTARY PUBLIC – STATE OF

Type or print name:

Commission No.:

(Seal) Commission Expires: