Freelance Subcontractor Insurance Declaration Form printable pdf download

Innovative Technologies, Inc.

Freelance Subcontractor Insurance Declaration Form

I hereby certify that the information below is true and correct and is based upon my personal knowledge:

1. My name is _______________________________________________________, and my current address is

_________________________________________________________________________________________.

2. I am over the age of eighteen (18) and am competent to testify in a court of law.

3. My trade is _________________________________________________________________, (TV production

technician, etc.)

4. I am in business for myself with no employees and I trade under the name of _________________________

___________________________________. My principal place of business is __________________________

__________________________________________________.

5. I have not elected to be a covered employee under Section 227 of the Labor and Employment

Article.

6. Last year, I filed a Schedule 1040 C with my federal tax return.

7. I provide my own tools for the work I perform.

8. (if applicable) I am a partner in _______________________________________________________________

(name of partnership), and I am not a covered employee under Section 9-219 of the Labor and Employment

Article.

THE FOLLOWING TWO SECTIONS MUST BE COMPLETED IN ORDER TO ACCEPT

ASSIGNMENTS FROM ITI.

WORKMAN'S COMPENSATION

I am an officer in _________________________________________________(name of

corporation) and I have elected to be exempt from Workman's Compensation coverage.

I do NOT possess Workman's Compensation coverage. I will not hold

Innovative Technologies, Inc. liable for any worker's compensation issues

that arise.

Signature: ______________________________ Witness: _____________________________

GENERAL LIABILITY INSURANCE

I further understand that I MUST possess General Liability Insurance in order to receive

any Independent Contractor assignments from ITI. My insurance carrier and policy # are:

(copy must be provided)

_______________________________________________________________

Signature: ______________________________ Witness: _____________________________

Freelance Subcontractor Insurance Declaration Form