Independent Contractor Waiver of Workers Compensation Coverage
I am an independent contractor, with no employees, no casual laborers, and no sub-contractors performing work for First Name. I am not the employee of First Name Last Name for workers’ compensation purposes, and therefore, I am not entitled to workers’ compensation benefits under their policy coverage. I waive any and all rights to file any claims against said employer in the event an accident should occur while I am performing work on their premises for the period of Date until Date.
First Name Last Name
Current Date
Signature