Leased_Employee_Affidavit.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.

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: _________________________________________