Leased_Employee_Affidavit.pdf
PDF 132 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 a Leased Employee Affidavit form required by the City of Port Orange, Florida's Purchasing Division for contractors awarded contracts with the municipality. The affidavit must be completed and submitted by the awarded bidder upon issuance of a Notice of Intent to Award and pertains to the City Center Sport Complex Ballfields Restoration project, which involves excavation, soil removal, waste material identification and disposal, geotextile membrane installation, fill replacement, and reconstruction of ballfields and associated site improvements. The form establishes the contractor's obligation to certify their workers' compensation coverage status and any reliance on employee leasing arrangements prior to commencing work on city jobsites.
The affidavit requires contractors to declare either that they do not utilize employee leasing companies or to provide complete documentation of their leasing arrangement and workers' compensation coverage if they do. Contractors employing leased workers must certify that 100 percent of their workforce is covered as enrolled worksite employees under the employee leasing company's workers' compensation policy and must agree to obtain separate coverage for any workers not included in the leasing arrangement. Contractors are obligated to provide the City with certificates of insurance evidencing workers' compensation coverage, notify the City of any changes to their leasing arrangements or carrier changes, and supply updated documentation prior to employee transitions or arrangement terminations. The affidavit serves as a risk management and compliance mechanism ensuring adequate worker protection throughout the project duration.
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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.
LEASED EMPLOYEE AFFIDAVIT
EXHIBIT CONTRACT #_____________
☐ I hereby certify that I do not utilize an employee leasing company or employ leased employees. I further agree to notify the City in the event these circumstances change.
OR
☐ I affirm that an employee leasing company provides my workers’ compensation coverage. I further understand that my contract with the employee leasing company limits my workers’ compensation coverage to enrolled worksite employees only. My leasing arrangement does not cover un-enrolled worksite employees, independent contractors, uninsured sub-contractors or casual labor exposure.
I hereby certify that 100% of my workers are covered as worksite employees with the employee leasing company. I certify that I do not hire any casual or uninsured labor outside the employee leasing agreement. I agree to notify the City in the event that I have any workers not covered by the employee leasing workers’ compensation policy. In the event that I have any workers not subject to the employee leasing arrangement, I agree to obtain a separate workers’ compensation policy to cover these workers. I further agree to provide the City with a certificate of insurance providing proof of workers’ compensation coverage prior to these workers entering any City jobsite.
I further agree to notify the City if my employee leasing arrangement terminates with the employee leasing company and I understand that I am required to furnish proof of replacement workers’ compensation coverage prior to the termination of the employee leasing arrangement.
I certify that I have workers’ compensation coverage for all of my workers through the employee leasing arrangement specified below:
Name of Employee Leasing Company: _____________________________________________________________________________________
Workers’ Compensation Carrier: ___________________________________________________________________________________________
A.M. Best Rating of Carrier: _________________
Inception Date of Leasing Arrangement: ___________________
I further agree to notify the City in the event that I switch employee leasing companies. I recognize that I have an obligation to supply an updated workers’ compensation certificate to the City that documents the change of carrier.
I hereby attest that the information provided in this affidavit is accurate. In addition, I certify that I have read and understand the above statements regarding my responsibility under the workers’ compensation coverage.
Name of Contractor: _____________________________________________________________________________________________________
Signature of Owner/Officer: _____________________________________________________________________________________________
Title: ______________________________________________________________________ Date: _________________________________________
File details come from the government source that posted it. Updated .