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Workers' Compensation Insurance Waiver

  1. Physical Address

  2. Mailing Address

  3. Please Read then Sign Below

  4. Declaration:

  5. With respect to the above-mentioned business, I hereby warrant that the business has no employees other than the owners, officers, directors, partners, or other principlas who have eleceted to be exempt from Worker's Compensation coverage in accordance with Colorado law and as a result I shall not have any cause of action of any kind under Article 40-47 of Title 8 of the CRS. I further warrant that I understand the requirements of the Workers Compensation Act of Colorado CRS 8-40-101 et seq with respect to providing Worker's Compensation coverage for any employees of the above mentioned business. I agree to comply with the code requirement and all other applicable laws and regulation regarding workers compensation. An Independent contractor is not entitled to workers' compensation benefits and the Independent contractor is obligated to pay federal and state income tax on any moneys earned pursuant to the contract relationship. I further agree to hold Grand County harmless from loss or liability which may arise from the failure of the above-mentioned business to comply with such laws or regulation. I therefore request that Grand County waive its requirement for evidence of Worker's Compensation Insurance.

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