Workers' Compensation Waiver Request Form
For three (3) employees or less, including part time and owner.
Total Number of Employees (including Owner): *
 Full TimePart Time
Number of Employees

Owner(s) maintains a separate business and uses their own supplies and equipment.
Owner(s) holds or has applied for a Federal Tax Identification Number (FEIN).
Owner(s) controls the way work is performed.
Owner(s) incurs expenses related to project, event, or agreement.
Owner(s) is liable for the failure to complete work or services.
Owner(s) will realize a profit or suffer a loss in connection with project, event or agreement.
Owner(s) has continuing or recurring business liabilities or obligations.
Owner(s) success or failure in business depends on business receipts or expenditures.
Owner(s) compensation is based on receipts from projects, events or agreements.
Owner(s) may hire subcontractors.

I understand that if I employ more than three (3) employees, or am in the Construction Industry, I must provide Pinellas County with Proof of Workers' Compensation Coverage.
* Your e-mail address is required to submit this form. E-mail addresses are public records under Florida law and are not exempt from public-records requirements.
If you do not want your e-mail address to be subject to being released pursuant to a public-records request, do not send electronic mail to this entity.
Instead, contact Pinellas County Risk Management by telephone at (727-464-3664), or in writing, via the United States Postal Service, to this address:
Pinellas County Risk Management
400 S. Fort Harrison Ave
Clearwater, FL 33756