TEXAS DEPARTMENT OF INSURANCE, DIVISION OF …

1 TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' compensation 7551 Metro Center Drive, Suite 100 Austin. TEXAS 78744 If you are not certain whether all parties meet the requirements for entering into this agreement, you may wis h to consult an attorney_ Tna5 Wo ' Compe nsatiOIl Act. TEXAS Labor COdl". S('clioll 406. 141121 t1 '~ " independcnt cOlltraClorft as follows: (2) " Independent ronlmeIOr" means a person who contracts In p<'rfnnn work Of pro\ ide a service for t he hellefil o f allo .he r and w ho: (AI \ paid by Ihe job. 1101 by the hour or S(lIllC o lher ti1!lC-lne9Su~d basis: (0) is free 10 h ire a s nmny h('lpe rs as he desires a nd 10 delenn ino: what e ach hclJXT will be paid: and Ie) is free 10 work for olher contractors. or to send he lpers \0 wor\.: for OIher contractors. while umler com met 10 the hiring. employer. CHECK 0 BOX OF STATEMENT THA T APPLIES o JOINT AGREEMENT TO AFFIRM INDEPENDENT RELA TIONSHIP FOR CERTAIN BUILDING AND CONSTRUCTION WORKERS Nolice of Declaration The unde rSigned lliring Contractor and the undersigned Inde pe ndent Contractor hereby declare tlml the Independe nt Contractor meets th e qualifient lnns o f an Inde pe nde nt Contracto r under TEXAS Workers' compensation Act, TEXAS Labor Code, 'Ct ioll , thnt the Independent Contractor is not an employee of the Hinng Contractor, find tha t: (A) the Independe nt Contractor and the Inde pendent Contractor's cmploy<es s hall not I:lc e nti tled to workers' compensation coverage h o m the Hiring Contrac tor.)))

2 A nd (B) the lliring ConlT3c to r's workers' compens'l tion ins urance carrie r s hall not require premiums to be by thc Hiring Contracto r fo r coverage o f the Indc lx:ndc m Cmllractor or the Independent Contrac tor's employees, helpers, o r s ubco ntrac tors. TillS DEC' TAKES EFFECT UPON RECEIPT BY TilE TEXAS DEI'ARTME1\T OF INSURAI\'CE, DlVISIO/\ OF WORKERS' COMI'ENSA nON. TillS APPLIES TO ALL HIRII\G AGREEMF1\TS EXECUTED BY THE HIRll\G CONTRACTOR At\'D THE INDEPENDENT CONTRACTOR DURll\G T11E YEAR AFTER TIllS DECLARATION IS FILED UNLESS A SUBS[QUEI\T UlRlt\'G AGREEMEI\'T IS MADE TO WHle11 THE DECLARATION DOES 1\'0 1 APPLY. It\' TilE TIIAT A HIRING AGREEMENT TO WHICH THIS DECLARATlO;.J DOES NOT APPLY IS MADE, THE HIRIt\G CONTRACTOR AND INDEPENDENT CONTRACTOR. SO >lOTIFY TlfE TEXAS DEPARTMENT OF Il\SURANCL DIVISION Of WORKERS' COMI'ENSATION AND mE HIRl t\G CONTRACTOR'S WORKERS' compensation INSURANCE CARRIER (If ANY) IN WRITII\'G WITIIIN 10 DAYS AFTER THI: I\'ON AI'I'LYING AGREEMENT IS MADE.]

3 0;-';(,[ THIS AGREEMENT IS SIGNED. TilE SUBCONTRACTOR AND THE SUBCONTRACTOR'S EMPLOYEES SHALL NOT BE ENTITLED TO WORKERS' COMPENSATIO>l COVERAGE FRO.'" TilE JIIRI;-.;G CONTRACTOR UNLESS A SUBSf QUEl\T WRITTEN AGREEMENT IS EXECUTED. AND FILED A( {"ORI1 ING TO WORKERS ~SAT ION , EXPRESSL Y STATING THAT TUIS AGREEME>lT DOE S :\'OT TEXAS Labor CC! Texa~ Workas compensation Act Scct ion o AGREEMENT TO ESTABLISH EMPLOYER-EMPLOYEE RELATIONSHIP FOR CERTAIN BUILDING AND CONSTRUCTION WORKERS Notice of Agreemt':1It The undcrsi),:ned Hiring COlllraClOr and the llndcl1>.lE!ed Indt'pcnde nt Contractor hereby agr~e that th e Hiring Contractor 0 will with hold U will 11()\ withhold the cost of workers.' compensation insurance coverage from t he Independent COll\ractor's contract price and that Ihe Hiring Contractor wilJ PUrch11SC workers' compensation insurance cuverage for t hc Ind~pendcnt ("Olllractor and the Indt'pendenl Contraetor'~ employees.))]}

4 O nce this agrcenl<:nt is signcd, for the purpose of providing workers' cnlJtpen~tioll in surance covcragc, the lliring Contractor will be the employer o f t he Independent Contractor aim the Independent C ontraclOr's employ e es. T his agr et'lI}!!nt makes the !Iinng Contractor thc employer of thc Independent Contractor and the Independent Contractor's employees only fo r t he purposes of workers' compensation 111I\'S o f TEXAS and for no Olher purpose. TERM ( DAT ES) O~ AGREEMENT: FROM, _____ _ TO, _____ _ LOCATION OF EACH AFFECT ED JOB SITE (OR STAT E WHETHER T HIS IS A BLANKET AGREEMENT): EST IMATED NUMBER OF EMPLOYEES AFFECTED, _____ _ THIS AGREEMENT SHALL TAKE E FFECT NO SOONEI{ THAN THE DATE IT IS SIGNED. TEXAS Labo r Codc. TEXAS Workers' ("om IISll tion Act, ScCl io n 406. 144. Hiring Contractor's Affirmation If the Hiring Contractor' s workers' compe nsation ranie r c hange during the effective p eriod of , it is advisable for the Hir in g Contractor to file this form with the n l'\\, insurancl' carrier.)

5 Signature orHiring Contract(lr Date PHARR & COMPANY Printed Name o f the Ilir ing Contractor 75-2187285 Federal T ax Number PO BOX 2791 Address (S treet) LUBBOCK, TX 79408 Address (City, State, Zip) Independent Contractor's Affirmation Federal Tax Number S ignature of Independent Contractor Date Address (Street) Printed Name ofth~ Independe nt Contractor Address (City, SL,te, Z ip) T he Hiring Confractor should r etain the original. Legible copies or this agreeme nt sho uld be filed with the hi ring eonlil lclor's workers compensation insurance carrier utld thl! DIVISION w ithin 10 days of the date of l'xecutioll. An agrel!lIIe nt is nOt cons idered filed if it is illegible o r incomplete. Fi ling may be ac complis hc d hy mail or facsilllile trans miss ioll. The Independent Contractor sho uld a lso retain a copy o f the agreeme nt. DIVISION Dale Stamp Here dwc form 83 (Rev. 10/05) DIVISION OF WORKERS' compensation )