Looking for a Cslb Forms And Templates? Download it for free!

CONTRACTORS STATE LICENSE BOARD

9821 Business Park Drive, Sacramento, CA 95827

STATE OF CALIFORNIA

Mailing Address: P.O. Box 26000, Sacramento, CA 95826

Arnold Schwarzenegger, Governor

800-321-CSLB (2752)

Exemption from Workers’ Compensation

Before the Contractors State License Board (CSLB) can issue a new license or reinstate, reactivate, or renew an existing license, the applicant

or licensee must have on file a Certificate of Workers’ Compensation Insurance or a Certificate of Self-Insurance issued by the Director of

Industrial Relations, or must obtain an exemption by completing and submitting these forms.

To be exempt from workers’ compensation, an applicant or licensee must submit this form to CSLB, certifying under penalty of perjury that

he or she does not employ anyone in a manner that is subject to the workers’ compensation laws of California. (See Business and Professions

Code Section 7125.)

DO NOT SUBMIT THIS FORM IF:

You have an inactive license.

The license qualifier is a Responsible Managing Employee (RME).

You have employees.

For exemption from workers’ compensation, you must complete the requested information, check only one of the boxes, and sign the form.

Please type or print neatly and legibly in black or dark blue ink.

SECTION 1 – BUSINESS NAME AND ADDRESS

FULL BUSINESS NAME (as it appears on the license)

CSLB LICENSE OR APPLICATION FEE NUMBER

BUSINESS MAILING ADDRESS number/street or P.O. box

city

state

ZIP code

BUSINESS STREET ADDRESS number/street only – NO P.O. boxes

city

state

ZIP code

BUSINESS PHONE NUMBER

BUSINESS FAX NUMBER

BUSINESS E-MAIL ADDRESS

(

)

(

)

□

CHECK THIS BOX IF THE ABOVE ADDRESS IS NEW.

SECTION 2 – REQUIRED CHECK BOX

YOU MUST CHECK ONLY ONE OF THE BOXES BELOW.

□

I do not employ anyone in the manner subject to the workers’ compensation laws of California.

□

I am an out-of-state contractor, and I do not hire employees who reside in California. (You must provide a certificate of insurance from

your workers’ compensation insurance carrier.)

SECTION 3 – REQUIRED SIGNATURE

FALSIFICATION OF ANY DOCUMENT IS GROUNDS FOR DISCIPLINARY ACTION.

I certify under penalty of perjury under the laws of the State of California that the information provided on this exemption statement is true and

accurate. I understand that, upon employing anyone in a manner that is subject to the workers’ compensation laws of the State of California, the

claim of exemption executed under this form will no longer be valid. I also understand that, as soon as I employ anyone subject to the California’s

workers’ compensation laws, I must obtain a Certificate of Workers’ Compensation Insurance, submit that certificate to CSLB within 90 days of its

effective date, and continuously maintain the coverage provided by the certificate in accordance with the law. I further understand that failure to

comply with this requirement is grounds for disciplinary action. (The definition of “perjury” is telling a lie while under oath.)

Date

Signature of Contractor (Owner, Partner, or Officer)

Printed Name of Contractor (Owner, Partner, or Officer)

Note:

For information on the collection of personal information, please refer to the General Information section at the

FOR CSLB USE ONLY

beginning of the application package, under the heading “Notice on Collection of Personal Information.”

*WC-EXEMPT*

Exemption from Workers’ Compensation – Page 1 of 1

13L-50 (rev. 09/05)

Form 13l-50 - Exemption From Workers' Compensation - Contractors State License Board, Sacramento, Ca

Related Articles

Related Categories