WORKERS' COMPENSATION EXEMPTION CERTIFICATION
Contractor / Entity Name:
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FEIN/Last Four of SSN:
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USDOT (if applicable):
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The undersigned contractor ("Contractor") certifies and represents to Keystone Cooperative, Inc. ("Company") as follows:
1. Contractor is an independent contractor hired by Company to perform the following services:
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Contractor is not an employee of Company. Company is responsible for determining and complying with all legal obligations applicable to its business operations, including workers' compensation requirements.
2. Contractor represents and certifies that it is not required to maintain workers' compensation insurance coverage under the laws applicable to Contractor's business and work being performed for Company. Contractor's claimed basis for exemption is (check all that apply):
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Sole proprietor with no employees.
Single-member limited liability company with no employees.
Partnership with no employees.
Corporation or limited liability company whose owners/officers are exempt under applicable law and which has no employees requiring coverage.
Independent contractor exempt from workers' compensation coverage under applicable state law.
Other
3. Contractor shall immediately notify Company in writing if: (i) Contractor's exemption status changes; (ii) Contractor hires employees; (iii) Contractor becomes required by law to maintain workers' compensation insurance; or (iv) Any representation made in this certification becomes inaccurate. Contractor shall provide evidence of workers' compensation insurance before performing any further services if coverage becomes required.
4. Contractor acknowledges that Company is relying on this certification in permitting Contractor to perform services. Contractor agrees that Contractor is solely responsible for compliance with all workers' compensation laws and regulations applicable to Contractor's business.
5. To the fullest extent permitted by law, Contractor agrees to defend, indemnify, and hold harmless Company and its affiliates, directors, officers, employees, agents, successors, and assigns from and against any claims, assessments, penalties, liabilities, costs, damages, losses, or expenses (including reasonable attorneys' fees) arising out of or relating to: (i) Contractor's failure to maintain workers' compensation coverage when required by law; (ii) Any inaccurate or false statement contained in this certification; or (iii) Any claim that Company is responsible for obtaining workers' compensation coverage on behalf of Contractor or Contractor's personnel.
6. Contractor certifies that the information provided in this certification is true, complete, and accurate as of the date signed below and understands that Company may rely upon this certification.
Under penalty of perjury, I hereby declare and affirm that the above-stated facts, to the best of my knowledge, are true and correct.
Signature:
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Printed Name:
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Title:
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Date:
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Month
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Day
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