Workers Compensation Waiver Request Form

Workers' Compensation Waiver Request Form

For three (3) employees or less, including part time and owner.

Business Name *

Today's Date * +

Contract#/Agreement#/Special Event Name *

Event Date * +

Total Number of Employees (including Owner): *

	Full Time	Part Time
Number of Employees	Full Time	Part Time

Owner(s) maintains a separate business and uses their own supplies and equipment.

Yes

Owner(s) holds or has applied for a Federal Tax Identification Number (FEIN).

Yes

Owner(s) controls the way work is performed.

Yes

Owner(s) incurs expenses related to project, event, or agreement.

Yes

Owner(s) is liable for the failure to complete work or services.

Yes

Owner(s) will realize a profit or suffer a loss in connection with project, event or agreement.

Yes

Owner(s) has continuing or recurring business liabilities or obligations.

Yes

Owner(s) success or failure in business depends on business receipts or expenditures.

Yes

Owner(s) compensation is based on receipts from projects, events or agreements.

Yes

Owner(s) may hire subcontractors.

Yes

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.

Business Owner's Electronic Signature *

Business Owner / CEO Name

Business Address

City

State

Zip Code

Phone Number

Email Address *

* 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