Free Workers Comp Waiver Layout Template
WORKERS COMP WAIVER LAYOUT
This Workers Compensation Waiver is a legal agreement between [Your Company Name] (hereafter referred to as the "Employer") and Johann Harvey, BlueLeaf (hereafter referred to as the "Subcontractor") working on projects in high-risk industries, including construction. This waiver clarifies the agreement on workers' compensation coverage, specifically for subcontractors who have their own insurance arrangements.
1. Purpose of the Waiver
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To outline and confirm that the Subcontractor will not be covered under [Your Company Name]’s workers' compensation insurance.
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To verify that the Subcontractor acknowledges their responsibility to maintain independent workers' compensation coverage.
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To provide clarity and prevent future disputes regarding liability for workplace injuries.
2. Parties Involved
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Employer: [Your Company Name]
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Subcontractor: Johann Harvey, BlueLeaf
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Project/Site Location: Miami, FL 33101
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Date of Agreement: January 15, 2050
3. Scope of Agreement
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This waiver applies exclusively to work performed by Johann Harvey, BlueLeaf on the Industrial Complex Development Project and does not constitute any form of employment relationship between [Your Company Name] and Johann Harvey, BlueLeaf.
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The Subcontractor will be working independently and will not be entitled to any workers' compensation benefits provided by [Your Company Name]
4. Acknowledgment of Independent Insurance Requirement
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Johann Harvey, BlueLeaf affirms that they have valid and current workers' compensation insurance coverage for themselves and their employees.
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The Subcontractor agrees to provide proof of such insurance coverage to [Your Company Name] upon request.
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The Subcontractor understands that, in the event of any work-related injury, [Your Company Name] bears no responsibility for coverage or compensation under [Your Company Name]’s workers’ compensation policy.
5. Indemnification Clause
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Johann Harvey, BlueLeaf agrees to indemnify, defend, and hold harmless [Your Company Name]. from any claims, losses, damages, or expenses arising out of injuries or accidents occurring while the Subcontractor performs work under this agreement.
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This includes claims by any employee or third party associated with Johann Harvey, BlueLeaf.
6. Waiver of Liability
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By signing this waiver, Johann Harvey, BlueLeaf waives any and all rights to workers' compensation claims against [Your Company Name].
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The Subcontractor acknowledges that they have no entitlement to benefits, compensation, or coverage under [Your Company Name]’s workers' compensation insurance policy.
7. Governing Law
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This waiver agreement shall be governed and construed in accordance with the laws of State of Illinois. Any disputes arising from this agreement shall be resolved under the jurisdiction of Illinois courts.
8. Signature Section
Jolie Cassin
Director of Operations, [Your Company Name]
Date: January 15, 2050
Johann Harvey, BlueLeaf
Owner, Johann Harvey, BlueLeaf
Date: January 15, 2050
Acknowledgment
By signing below, the Subcontractor affirms that they have read, understood, and agreed to the terms of this Workers Compensation Waiver. The Subcontractor acknowledges that this waiver is binding and that they fully assume responsibility for their own workers' compensation insurance.
