Joint Agreement To Affirm Independent Relationship For Certain Building And Construction Workers, Agreement To Establish Employeremployee Relationship For Certain Building And Construction Workers

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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.
Texas Workers' Compensation Act, Texas Labor Code, Section 406.141(2) defines "independent contractor" as follows: (2) "Independent contractor" means a person who contracts to perform work or
provide a service for the benefit of another and who: (A) is paid by the job, not by the hour or some other time-measured basis; (B) is free to hire as many helpers as he desires and to determine what each
helper will be paid; and (C) is free to work for other contractors, or to send helpers to work for other contractors, while under contract to the hiring employer.
CHECK
BOX OF STATEMENT THAT APPLIES
JOINT AGREEMENT TO AFFIRM INDEPENDENT
AGREEMENT TO ESTABLISH EMPLOYER-
RELATIONSHIP FOR CERTAIN BUILDING
EMPLOYEE RELATIONSHIP FOR CERTAIN
AND CONSTRUCTION WORKERS
BUILDING AND CONSTRUCTION WORKERS
Notice of Declaration
Notice of Agreement
The undersigned Hiring Contractor and the undersigned Independent Contractor hereby agree
The undersigned Hiring Contractor and the undersigned Independent Contractor
that the Hiring Contractor
will withhold
will not withhold the cost of workers'
hereby declare that the Independent Contractor meets the qualifications of an
compensation insurance coverage from the Independent Contractor's contract price and that the
Independent Contractor under Texas Workers' Compensation Act, Texas Labor
Hiring Contractor will purchase workers' compensation insurance coverage for the Independent
Code, Section 406.141, that the Independent Contractor is not an employee of the
Contractor and the Independent Contractor's employees. Once this agreement is signed, for the
Hiring Contractor, and that:
purpose of providing workers' compensation insurance coverage, the Hiring Contractor will be
the employer of the Independent Contractor and the Independent Contractor's employees. This
(A) the Independent Contractor and the Independent Contractor's employees
agreement makes the Hiring Contractor the employer of the Independent Contractor and the
Independent Contractor's employees only for the purposes of workers' compensation laws of
shall not be entitled to workers' compensation coverage from the Hiring
Texas and for no other purpose.
Contractor; and
(B) the Hiring Contractor's workers' compensation insurance carrier shall not
TERM (DATES) OF AGREEMENT:
FROM: _____________________
require premiums to be paid by the Hiring Contractor for coverage of the
Independent Contractor or the Independent Contractor's employees,
TO: ________________________
helpers, or subcontractors.
__________________________________________________________________
LOCATION OF EACH AFFECTED JOB SITE (OR STATE WHETHER THIS
THIS
DECLARATION
TAKES
EFFECT
UPON
RECEIPT
BY
THE
TEXAS
DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION. THIS
IS A BLANKET AGREEMENT):
DECLARATION APPLIES TO ALL HIRING AGREEMENTS EXECUTED BY THE
_________________________________________________________________
HIRING CONTRACTOR AND THE INDEPENDENT CONTRACTOR DURING THE
YEAR AFTER THIS DECLARATION IS FILED UNLESS A SUBSEQUENT HIRING
__________________________________________________________________
AGREEMENT IS MADE TO WHICH THE DECLARATION DOES NOT APPLY. IN THE
EVENT THAT A HIRING AGREEMENT TO WHICH THIS DECLARATION DOES NOT
___________________________________________________________________
APPLY IS MADE, THE HIRING CONTRACTOR AND INDEPENDENT CONTRACTOR
SHALL SO NOTIFY THE TEXAS DEPARTMENT OF INSURANCE, DIVISION OF
WORKERS' COMPENSATION AND THE HIRING CONTRACTOR'S WORKERS'
ESTIMATED NUMBER OF EMPLOYEES AFFECTED: _________________
COMPENSATION INSURANCE CARRIER (IF ANY) IN WRITING WITHIN 10 DAYS
AFTER THE NON-APPLYING AGREEMENT IS MADE. ONCE THIS AGREEMENT IS
THIS AGREEMENT SHALL TAKE EFFECT NO SOONER THAN THE DATE
SIGNED, THE SUBCONTRACTOR AND THE SUBCONTRACTOR'S EMPLOYEES
IT IS SIGNED.
SHALL NOT BE ENTITLED TO WORKERS' COMPENSATION COVERAGE FROM THE
HIRING CONTRACTOR UNLESS A SUBSEQUENT WRITTEN AGREEMENT IS
EXECUTED, AND FILED ACCORDING TO WORKERS’ COMPENSATION RULES,
EXPRESSLY STATING THAT THIS AGREEMENT DOES NOT APPLY.
Texas Labor Code, Texas Workers’ Compensation Act, Section 406.145.
Texas Labor Code, Texas Workers’ Compensation Act, Section 406.144.
Hiring Contractor's Affirmation
If the Hiring Contractor's workers' compensation carrier change
during the effective period of coverage, it is advisable for the Hiring Contractor
__________________________________
to file this form with the new insurance carrier.
Federal Tax I.D. Number
______________________________________________
______________________
________________________________________________________________
Signature of Hiring Contractor
Date
Address (Street)
________________________________________________________________________
________________________________________________________________
Printed Name of the Hiring Contractor
Address (City, State, Zip)
Independent Contractor's Affirmation
____________________________
Federal Tax I.D. Number
______________________________________________
______________________
________________________________________________________________
Signature of Independent Contractor
Date
Address (Street)
________________________________________________________________________
________________________________________________________________
Printed Name of the Independent Contractor
Address (City, State, Zip)
The Hiring Contractor should retain the original. Legible copies of this agreement should be filed with the hiring contractor’s workers’ compensation insurance carrier and
the Division within 10 days of the date of execution. An agreement is not considered filed if it is illegible or incomplete. Filing may be accomplished by mail or facsimile
transmission. The Independent Contractor should also retain a copy of the agreement.
Division Date Stamp Here
DWC FORM-83 (Rev. 10/05)
DIVISION OF WORKERS’ COMPENSATION

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