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Exception To Application Of Joint Agreement To Affirm Independent Relationship For Certain Building And Construction Workers DWC-84 - Texas
| Exception To Application Of Joint Agreement To Affirm Independent Relationship For Certain Building And Construction Workers 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 EXCEPTION TO APPLICATION OF JOINT AGREEMENT TO AFFIRM INDEPENDENT RELATIONSHIP FOR CERTAIN BUILDING AND CONSTRUCTION WORKERS NOTICE OF DECLARATION The undersigned Hiring Contractor and the undersigned Independent Contractor declare that the Joint Agreement to Affirm Independent Relationship for Certain Building and Construction Workers (as recorded on DWC FORM-83) does not apply to the subsequent hiring agreement between the Hiring Contractor and Independent Contractor. Nothing in this declaration otherwise nullifies the Joint Agreement to Affirm Independent Relationship for Certain Building and Construction Workers as it applies to other hiring agreements made during the term of the joint agreement. DATE OF JOINT AGREEMENT TO AFFIRM INDEPENDENT RELATIONSHIP FOR CERTAIN BUILDING AND CONSTRUCTION WORKERS DATE OF SUBSEQUENT HIRING AGREEMENT TO WHICH THIS FORM APPLIES LOCATION OF SPECIFIC JOB SITES NOT AFFECTED BY JOINT AGREEMENT: NAME OF HIRING CONTRACTOR NAME OF INDEPENDENT CONTRACTOR Hiring Contractor's Affirmation If the Hiring Contractor's workers' compensation carrier changes during the effective period of coverage, it is advisable for the Hiring Contractor to file this form with the new insurance carrier. Federal Tax I.D. Number Signature of Hiring Contractor Date Address (Street) Printed Name of Hiring Contractor Address (City, State, Zip) Independent Contractor's Affirmation Federal Tax I.D. Number Signature of Independent Contractor Date Address (Street) Printed Name of Independent Contractor Address (City, State, Zip) Four copies of this form must be completed: This agreement must be filed by the Hiring Contractor with both the Texas Department of Insurance, Division of Workers' Compensation and the workers' compensation insurance carrier of the Hiring 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 CERTIFIED MAIL. Both the Hiring Contractor and the Independent Contractor must also retain a copy of the agreement. Division Date Stamp Here DWC FORM-84 (Rev 10/05) DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.USCourtForms.com
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