Sample Exhibit 4.pdf
PDF 84 KB Posted
- Attached to
- Chronic Disease Prevention and Health Promotion
- Solicitation number
- RFPQ-117-2023
- Issued by
- Multnomah County, Oregon
About this file
This document is a Workers' Compensation Exemption Certificate for a Multnomah County Services Contract, marked as a sample document not intended for submission. The form provides a mechanism for contractors to claim exemption from workers' compensation insurance coverage requirements under Oregon Revised Statutes (ORS) Chapter 656. The certificate offers five distinct exemption categories: Sole Proprietor, For-Profit Corporation, Nonprofit Corporation, Partnership, and Limited Liability Company, each with specific qualifying conditions such as having no employees, performing all work through owners/partners/members, and not engaging in certain types of construction-related work.
The document includes detailed notes clarifying exemption criteria, such as defining "substantial ownership" for corporate shareholders (10% ownership or equivalent) and cautioning that exemptions for partnerships and limited liability companies performing construction work are complex. Contractors must carefully review and accurately complete the appropriate section, signing and dating the form to validate their workers' compensation insurance exemption status. The form serves as a critical compliance document for contractors engaged with Multnomah County, ensuring transparency and legal adherence to state workforce regulations.
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Text version
05/29/13 CAL Exhibit 4 Page 1 of 1
EXHIBIT 4
MULTNOMAH COUNTY SERVICES CONTRACT
Contract No. SAMPLE Contract – Do Not Submit
Workers’ Compensation Exemption Certificate
(To be used only when Contractor claims to be exempt from Workers’ Compensation coverage requirements)
Contractor is exempt from the requirement to obtain workers’ compensation insurance under ORS Chapter 656 for the following reason (check the appropriate box):
SOLE PROPRIETOR
Contractor is a sole proprietor, and
Contractor has no employees, and
Contractor will not hire employees to perform this Contract.
CORPORATION – FOR PROFIT
Contractor’s business is incorporated, and
All employees of the corporation are officers and directors and have a substantial ownership interest* in the corporation, and
All Work will be performed by the officers and directors; Contractor will not hire other employees to perform this Contract.
CORPORATION – NONPROFIT
Contractor’s business is incorporated as a nonprofit corporation, and
Contractor has no employees; all Work is performed by volunteers, and
Contractors will not hire employees to perform this Contract.
PARTNERSHIP
Contractor is a partnership, and
Contractor has no employees, and
All Work will be performed by the partners; Contractor will not hire employees to perform this Contract, and
Contractor is not engaged in work performed in direct connection with the construction, alteration, repair, improvement, moving or demolition of an improvement to real property or appurtenances thereto.**
LIMITED LIABILITY COMPANY
Contractor is a limited liability company, and
Contractor has no employees, and
All Work will be performed by the members; Contractor will not hire employees to perform this Contract, and
If Contractor has more than one member, Contractor is not engaged in work performed in direct connection with the construction, alteration, repair, improvement, moving or demolition of an improvement to real property or appurtenances thereto.**
*NOTE: Under OAR436-50-0005 a shareholder has a “substantial ownership” interest if the shareholder owns 10% of the corporation, or if less than 10% is owned, the shareholder has ownership that is at least equal to or greater than the average percentage of ownership of all shareholders.
**NOTE: Under certain circumstances partnerships and limited liability companies can claim an exemption even when performing construction work. The requirements for this exemption are complicated. Consult with County Counsel before an exemption request is accepted from a Contractor who will perform construction work.
Contractor Printed Name:
Contractor Signature:
Contractor Title:
Date:
File details come from the government source that posted it. Updated .