Workers' Compensation Waiver Request Form
 
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Number of Employees (including Owner): *
 Full TimePart Time
Number of Employees

He/She maintains a separate business and utilizes/supplies his or her own equipment.
He/She holds or has applied for a Federal Tax Identification Number (TIN).
He/She controls the means of performing the work.
He/She is incurring the principal expenses related to the project.
He/She is liable for the failure to complete the work or services.
He/She will realize a profit or suffer a loss in connection with the project.
He/She has continuing or recurring business liabilities or obligations.
His/Her success or failure in business depends on the business receipts or expenditures.
His/Her compensation is not based upon an hourly rate.
He/She will hire subcontractors.

I UNDERSTAND THAT IF I EMPLOY MORE THAN THREE (3) EMPLOYEES, 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, 3rd Floor
Clearwater, FL 33756