Request For Waiver Of Workers' Compensation Insurance Requirement And Waiver Of Claims printable pdf download

Contracts and Procurement

Request for Waiver of Workers’ Compensation Insurance Requirement

and Waiver of Claims

Business Legal Name: ______________________________________________________________________________

Address: _________________________________________________________________________________________

_________________________________________________________________________________________

Legal Form:

Sole Proprietor

Other: ______________________________________________________

Contact Person: ____________________________________

Telephone: ________________________________

Nature of work to be performed for the University: _______________________________________________________

Declaration:

With respect to the above-mentioned business, I hereby warrant that the business has no employees other than

the owners, officers, directors, partners or other principals who have elected to be exempt from Workers’

Compensation coverage in accordance with California law. I further warrant that I understand the requirements

of Section 3700 et seq. of the California Labor Code with respect to providing Worker’s Compensation coverage

for any employees of the above mentioned business. I agree to comply with the code requirements and all other

applicable laws and regulations regarding Workers’ Compensation, payroll taxes, FICA and tax withholding and

similar employment issues. I further agree to hold California State University, Fullerton (“University”) harmless

from loss or liability which may arise from the failure of the above-mentioned business to comply with any such

laws or regulations. I therefore request that the University waive its requirement for evidence of Workers’

Compensation insurance in connection with the above-referenced work.

Acknowledging that I do not have Workers’ Compensation coverage, I agree not to bring any claims against the

University, which claims concern any injury, death or disability that potentially would have been covered by

Workers’ Compensation, including any work-related injuries which arise out of or are in any way connected

with the performance of my obligations under the contract, and including any claims that could be covered by

the University’s Workers’ Compensation coverage. I also agree to defend, hold harmless and indemnify the

University for any such claims. I further acknowledge that prior to signing this waiver, I was given the

opportunity to contact an attorney and that I understand and knowingly execute this document. I understand and

acknowledge that this waiver is binding on me as well as my heirs and assigns.

Signatures:

_____________________________________________

Owner, Officer, Director, Partnership or Other Principal

(If the form of the business is a partnership, all partners must sign)

_____________________________________________

Print Name(s)

_____________________________________________

Title

_____________________________________________

Date

2600 East Nutwood Avenue, Suite 300 Fullerton, CA 92831

P 657-278-2411 / F 657-278-5230 / E-Mail procurement@fullerton.edu

Request For Waiver Of Workers' Compensation Insurance Requirement And Waiver Of Claims