Sample Exhibit 4.pdf
PDF 84 KB Posted
- Attached to
- Presort Mail and Mail Insert Services
- Solicitation number
- ITB-44-2025
- Issued by
- Oregon
About this file
This document is a Workers' Compensation Exemption Certificate for a Multnomah County Services Contract, marked as a sample document not to be submitted. The form provides a template for contractors to claim exemption from workers' compensation insurance coverage requirements under Oregon Revised Statutes (ORS) Chapter 656. The exemption can be claimed by different business types including sole proprietors, for-profit and nonprofit corporations, partnerships, and limited liability companies, each with specific qualifying conditions such as having no employees or having all work performed by owners/partners.
The certificate outlines detailed conditions for exemption, including restrictions on hiring employees, performance of work by owners/partners, and special considerations for corporations and multi-member entities. The document includes important notes about defining "substantial ownership" for shareholders and cautions about exemption claims for construction-related work, recommending consultation with County Counsel for complex scenarios. The form is designed to be completed by the contractor, requiring their printed name, signature, title, and date to validate the workers' compensation insurance exemption claim.
View the file
Other files
Show all 11
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .