Agreement Between General Contractor And Subcontractor

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TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION

7551 Metro Center Drive, Suite 100

Austin, Texas 78744

If you are not certain whether all parties meet the requirements for entering into this agreement, you may wish to consult an attorney.

AGREEMENT BETWEEN GENERAL CONTRACTOR AND SUBCONTRACTOR

TO PROVIDE WORKERS' COMPENSATION INSURANCE

Notice of Agreement

The undersigned General Contractor and the undersigned Subcontractor hereby agree that the General Contractor

will withhold

will not withhold the cost of

workers' compensation insurance coverage from the Subcontractor's contract price and that, for the purpose of providing workers' compensation insurance coverage, the

General Contractor will be the employer of the Subcontractor and the Subcontractor's employees. This agreement makes the General Contractor the employer of the

Subcontractor and the Subcontractor's employees only for the purposes of workers' compensation laws of Texas and for no other purpose.

TERM (DATES) OF AGREEMENT:

FROM:

TO:

LOCATION OF EACH AFFECTED JOB SITE (OR STATE WHETHER THIS IS A BLANKET AGREEMENT):

ESTIMATED NUMBER OF EMPLOYEES AFFECTED:

THIS AGREEMENT SHALL TAKE EFFECT NO SOONER THAN THE DATE IT IS SIGNED.

Texas Labor Code, Texas Workers’ Compensation Act, Section 406.123

General Contractor's Affirmation

If the General Contractor's workers' compensation carrier changes

Federal Tax I.D. Number

during the effective period of coverage, it is advisable for the General Contractor

to file this form with the new insurance carrier.

Signature of General Contractor

Date

Address (Street)

Printed Name of General Contractor

Address (City, State, Zip)

Subcontractor's Affirmation

Federal Tax I.D. Number

Signature of Subcontractor

Date

Address (Street)

Printed Name of Subcontractor

Address (City, State, Zip)

The General Contractor should retain the original. Legible copies of this agreement should be filed with the general contractor’s workers’ compensation insurance

carrier and the Division within 10 days of the date of execution. If the General Contractor is certified self-insured, a copy should be filed with the Division’s Self-

Insurance Regulation service area. An agreement is not considered filed if it is illegible or incomplete. Filing may be accomplished by mail or facsimile transmission.

The Subcontractor must also retain a copy of the agreement.

Division Date Stamp Here

DWC FORM-81 (Rev. 10/05)

DIVISION OF WORKERS’ COMPENSATION