Vendor Workers' Compensation Waiver Form printable pdf download

VENDOR WORKERS’ COMPENSATION WAIVER FORM

We are required to maintain verification regarding workers’ compensation coverage for all of our vendors that

are contracted to provide a service and to release the City of Romulus of any and all liability for injuries that

may occur while conducting business on City of Romulus Property.

1) Name of Vendor: (same as it appears on the W-9 form) _______________________________________________

2) Federal Tax Identification Number or last 4 digits of Social Security No.

_______________________________

3) Number of Employees: ____________

4) _______ I DO NOT carry Worker’s Compensation Insurance. Please fill out the bottom half of this form. City

Clerk is available for FREE notary services. (Monday – Friday, 8:00 am – 5:00 pm)

5) _______ I DO carry Worker’s Compensation Insurance. Please attach a current Certificate of Insurance that

displays workers’ compensation coverage for the period of time the services will be performed for

the City.

----------------------------------------------------------------------------------------------------------------------------- -------------------------------------

DO NOT

Please complete the following if you

have Workers’ Compensation Insurance:

In consideration of the work I am performing for the City of Romulus and/or it’s departments and affiliates; and

in lieu of required Workers’ Compensation insurance, I hereby release and discharge, the City of Romulus, its

Mayor, Council Members, Employees and Agents, from all liability to the undersigned, his/her personal

representatives, employees, assigns, heirs and next of kin, for any and all loss or damage, and any claim or

demand based on injury to myself or my employee(s) that might occur while doing the work as agreed. I

agree to be solely responsible for my own, and my employee(s) medical expenses.

Dated at: ____________________________ , on this ___________ day of ________________ ,_______________

Signed: _________________________________________________________________________________________

STATE OF MICHIGAN, COUNTY OF _________________________________________________________________

On this ___________________day of _________________, ___________________before me personally appeared

______________________, who being duly sworn did state that s/he is not entitled to workers’ compensation

benefits as indicated under Michigan’s Law.

Seal/Stamp

___________________________________________________________

Notary Public, _______________________________________County

My Commission expires_____________________________________

Vendor Workers' Compensation Waiver Form

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