W_C Exemption.pdf
PDF 106 KB Posted
- Solicitation number
- RFP_F-Contr-0000000107
- Issued by
- Contra Costa County, California
About this file
This document is a Workers' Compensation Exemption form detailing legal requirements for a contractor with no employees other than owners, officers, directors, partners, or principals who have elected to be exempt from Workers' Compensation coverage in California. The form outlines the contractor's obligations under California Labor Code Section 3700, which mandates that employers with one or more employees must be insured against workers' compensation liability or undertake self-insurance.
The form specifically requires the contractor to acknowledge that if they hire an employee during the contract period, their exemption status becomes invalid. In such a case, the contractor must immediately cease work, obtain a Workers' Compensation Insurance Certificate, and submit it to the County. The contractor must maintain this coverage in accordance with California law throughout the duration of the contract. The document provides signature lines for the contractor to attest to their understanding and compliance with these requirements.
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Text version
Workers’ Compensation Exemption – Certifying No Employees.
With respect to the Contractor’s services to this contract, the business has no employees other than the owners, officers, directors, partners or other principals who have elected to be exempt from Workers’ Compensation coverage in accordance with California law. Contractor is aware of the provisions of California Labor Code Section 3700, which requires every employer having one or more employees to be insured against liability for workers’ compensation or to undertake self‐insurance in accordance with the provisions of that code.
Contractor understands that if while performing the work identified herein, employs someone to become subject to the Workers Compensation Laws of California, the claim of exemption executed under this paragraph will no longer be valid. Contractor further affirm that if subject to the Workers' Compensation Laws of California while performing the work under this Contract, will immediately cease work and obtain a Certificate of Workers’ Compensation Insurance, submit that Certificate to the County immediately following its effective date, and at all times when performing services under this Contract maintain the coverage provided by the Certificate in accordance with the law.
Contractor Signed:_______________ Initials:
Printed:________________________ Date:
File details come from the government source that posted it. Updated .