Affidavit Of Rejection Of Coverage For Workers' Compensation Form
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1Contract:
________ GS ________________
________ IC ________________
AFFIDAVIT OF REJECTION OF COVERAGE
FOR WORKERS’ COMPENSATION
UNDER NRS 616B.627 and NRS 617.210
STATE OF NEVADA )
) ss.
_________ COUNTY )
___________________, being first duly sworn, deposes and states:
1. I make the following assertions pursuant to NRS 616B.627 and NRS 617.210.
2. I am a sole proprietor who will not use the services of any employees in the
performance of this Contract with the Nevada System of Higher Education.
3. In accordance with the provisions of NRS 616B.659, I have not elected to be
included within the terms, conditions and provisions of chapters 616A to 616D,
inclusive, of NRS, relating thereto.
4. I am otherwise in compliance with the terms, conditions and provisions of
chapters 616A to 616D, inclusive, of NRS.
5. In accordance with the provisions of NRS 617.225, I have not elected to be
included within the terms, conditions and provisions of chapter 617 of NRS.
6. I am otherwise in compliance with the terms, conditions and provisions of chapter
617 of NRS.
7. I acknowledge that the Nevada System of Higher Education will not be
considered to be my employer or the employer of my employees, if any; and that
the Nevada System of Higher Education is not liable as a principal contractor to
me or my employees, if any, for any compensation or other damages as a result
of an industrial injury or occupational disease incurred in the performance of this
Contract.
8. Further affiant sayeth not.
I, ________________, do hereby swear under penalty of perjury that the
assertions of this affidavit are true.
_____________________________
NAME________________________
SIGNED and SWORN to before me this ___ day of _____________, _______,
by _________________.
_____________________________
NOTARY PUBLIC
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