Dwc Form 85 - Agreement Between General Contractor And Subcontractor - Texas Department Of Insurance

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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 406.121(2) defines "independent contractor" as follows: (1) "Independent contractor" means a person who contracts to perform

work or provide a service for the benefit of another and who ordinarily: (A) acts as the employer of any employee of the contractor by paying wages, directing activities, and performing other

similar functions characteristic of an employer-employee relationship; (B) is free to determine the manner in which the work or service is performed, including the hours of labor of or method

of payment to any employee; (C) is required to furnish or have his employees, if any, furnish necessary tools, supplies, or materials to perform the work or service; and (D) possesses the skills

required for the specific work or service.

AGREEMENT BETWEEN GENERAL CONTRACTOR AND SUBCONTRACTOR

TO ESTABLISH INDEPENDENT RELATIONSHIP

Notice of Agreement

The undersigned General Contractor and the undersigned Subcontractor hereby declare that:

(A)

the Subcontractor meets the qualifications of an Independent Contractor under Texas Workers' Compensation Act, Texas Labor

Code, Section 406.121;

(B)

the Subcontractor is operating as an independent contractor as that term is defined under Section 406.121 of the Act;

(C)

the Subcontractor assumes the responsibilities of an employer for the performance of work; and

(D)

the Subcontractor and the Subcontractor's employees are not employees of the General Contractor for purposes of the Act.

TERM (DATES) OF AGREEMENT:

FROM:

TO:

Name of General Contractor

Name of Subcontractor

LOCATION OF EACH AFFECTED JOB SITE (OR STATE WHETHER

Estimated number of employees affected:___________

THIS IS A BLANKET AGREEMENT):

THIS AGREEMENT SHALL TAKE EFFECT NO SOONER THAN THE

DATE IT IS SIGNED.

Texas Labor Code, Texas Workers’ Compensation Act, Section 406.122 .

General Contractor's Affirmation

If the General Contractor's workers' compensation carrier changes

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

Federal Tax I. D. Number

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. The Subcontractor should also retain a copy of the agreement.. This form is not required to be filed with the

Division, and may be provided to the insurance carrier.

Division Data Stamp Here

DWC FORM-85 (Rev. 10/05)

DIVISION OF WORKERS’ COMPENSATION