Contractor Worksite Insurance Waiver Form
Complete this form to acknowledge worksite risks and confirm insurance coverage for your assignment.
Contractor Full Name
*
First Name
Last Name
Company Name
*
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Project or Worksite Location
*
Work Start and End Dates
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Work Being Performed
*
Emergency Contact Name and Phone Number
*
Does your company currently maintain active insurance coverage appropriate for this assignment?
*
Yes
No
By checking this box, I acknowledge the risks associated with worksite activities and confirm that my company maintains appropriate insurance coverage for this assignment.
*
I acknowledge and confirm
Submit Waiver
Should be Empty: