Texas > Workers Compensation > Agreement
Agreement Between General Contractor And Subcontractor To Provide Workers Compensation Insurance DWC-81 - Texas
| Agreement Between General Contractor And Subcontractor To Provide Workers Compensation Insurance Form. This is a Texas form and can be used in Agreement Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
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. AGREEMENT BETWEEN GENERAL CONTRACTOR AND SUBCONTRACTOR TO PROVIDE WORKERS' COMPENSATION INSURANCE Notice of Agreement The undersigned General Contractor and the undersigned Subcontractor hereby agree that the General Contractor will withhold will not withhold the cost of workers' compensation insurance coverage from the Subcontractor's contract price and that, for the purpose of providing workers' compensation insurance coverage, the General Contractor will be the employer of the Subcontractor and the Subcontractor's employees. This agreement makes the General Contractor the employer of the Subcontractor and the Subcontractor's employees only for the purposes of workers' compensation laws of Texas and for no other purpose. TERM (DATES) OF AGREEMENT: FROM: TO: LOCATION OF EACH AFFECTED JOB SITE (OR STATE WHETHER THIS IS A BLANKET AGREEMENT): 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 both the Texas Department of Insurance, Division of Workers' Compensation and the workers' compensation insurance carrier of the General Contractor within 10 days of the date of execution. The original must be filed with the Division. The agreement must be filed by PERSONAL DELIVERY OR REGISTERED OR CERTIFIED MAIL. Failure to file this agreement may result in a fine of up to $5,000. Both the General Contractor and the Subcontractor must also retain a copy of the agreement. Division Date Stamp Here DWC FORM-81 (Rev. 10/05) DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.USCourtForms.com
|
|||||||
