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Agreement Between General Contractor And Subcontractor To Establish Independant Relationship DWC-85 - Texas
| Agreement Between General Contractor And Subcontractor To Establish Independant Relationship Form. This is a Texas form and can be used in Agreement Workers Compensation . |
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TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION 7551 Metro Center Drive, Suite 100 Austin, Texas 78744 If you are not certain whether all parties meet the requirements for entering into this agreement, you may wish to consult an attorney. Texas Workers' Compensation Act, Texas Labor Code, Section 406.121(2) defines "independent contractor" as follows: (1) "Independent contractor" means a person who contracts to perform work or provide a service for the benefit of another and who ordinarily: (A) acts as the employer of any employee of the contractor by paying wages, directing activities, and performing other similar functions characteristic of an employer-employee relationship; (B) is free to determine the manner in which the work or service is performed, including the hours of labor of or method of payment to any employee; (C) is required to furnish or have his employees, if any, furnish necessary tools, supplies, or materials to perform the work or service; and (D) possesses the skills required for the specific work or service. AGREEMENT BETWEEN GENERAL CONTRACTOR AND SUBCONTRACTOR TO ESTABLISH INDEPENDENT RELATIONSHIP Notice of Agreement The undersigned General Contractor and the undersigned Subcontractor hereby declare that: (A) (B) (C) (D) the Subcontractor meets the qualifications of an Independent Contractor under Texas Workers' Compensation Act, Texas Labor Code, Section 406.121; the Subcontractor is operating as an independent contractor as that term is defined under Section 406.121 of the Act; the Subcontractor assumes the responsibilities of an employer for the performance of work; and the Subcontractor and the Subcontractor's employees are not employees of the General Contractor for purposes of the Act. TERM (DATES) OF AGREEMENT: FROM: TO: Name of General Contractor LOCATION OF EACH AFFECTED JOB SITE (OR STATE WHETHER THIS IS A BLANKET AGREEMENT): Name of Subcontractor Estimated number of employees affected:___________ THIS AGREEMENT SHALL TAKE EFFECT NO SOONER THAN THE DATE IT IS SIGNED. General Contractor's Affirmation If the General Contractor's workers' compensation carrier changes during the effective period of coverage, it is advisable for the General Contractor to file this form with the new insurance carrier. Federal Tax I. D. Number Signature of General Contractor Date Address (Street) Printed Name of General Contractor Address (City, State, Zip) Subcontractor's Affirmation Federal Tax I. D. Number Signature of Subcontractor Date Address (Street) Printed Name of Subcontractor Address (City, State, Zip) Four copies of this form must be completed: This agreement must be filed by the General Contractor with workers' compensation insurance carrier of the General Contractor within 10 days of the date of execution. The original must be filed with the insurance carrier by PERSONAL DELIVERY OR REGISTERED OR CERTIFIED MAIL. Both the General Contractor and the Subcontractor must also retain a copy of the agreement. Division Data Stamp Here American LegalNet, Inc. DWC FORM-85 (Rev. 10/05) DIVISION OF WORKERS' COMPENSATION www.USCourtForms.com
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