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Get TX DWC Form-85 2005

Texas Labor Code Texas Workers Compensation Act Section 406. 122. General Contractor s Affirmation If the General Contractor s workers compensation carrier changes during the effective period of coverage it is advisable for the Signature of General Contractor Date Printed Name of General Contractor Federal Tax I. D. Number Address Street Address City State Zip Subcontractor s Affirmation Signature of Subcontractor The General Contractor should retain the original. The Subcontractor should also retain a copy of the agreement. This form is not required to be filed with the Division and may be provided to the insurance carrier. 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 wish to consult an attorney. Texas Workers Compensation Act Texas Labor Code Section 406. 121 2 defines independent contractor as follows 1 Independent contractor means a person who contracts to perform work or provide a service for the benefit of another and who ordinarily A acts as the employer of any employee of the contractor by paying wages directing activities and performing other similar functions characteristic of an employer-employee relationship B is free to determine the manner in which the work or service is performed including the hours of labor of or method of payment to any employee C is required to furnish or have his employees if any furnish necessary tools supplies or materials to perform the work or service and D possesses the skills required for the specific work or service. AGREEMENT BETWEEN GENERAL CONTRACTOR AND SUBCONTRACTOR TO ESTABLISH INDEPENDENT RELATIONSHIP Notice of Agreement The undersigned General Contractor and the undersigned Subcontractor hereby declare that A B C D the Subcontractor meets the qualifications of an Independent Contractor under Texas Workers Compensation Act Texas Labor Code Section 406. 121 TERM DATES OF AGREEMENT FROM TO Name of General Contractor Name of Subcontractor LOCATION OF EACH AFFECTED JOB SITE OR STATE WHETHER THIS IS A BLANKET AGREEMENT Estimated number of employees affected THIS AGREEMENT SHALL TAKE EFFECT NO SOONER THAN THE DATE IT IS SIGNED. Texas Labor Code Texas Workers Compensation Act Section 406. 122. General Contractor s Affirmation If the General Contractor s workers compensation carrier changes during the effective period of coverage it is advisable for the Signature of General Contractor Date Printed Name of General Contractor Federal Tax I. D. Number Address Street Address City State Zip Subcontractor s Affirmation Signature of Subcontractor The General Contractor should retain the original* The Subcontractor should also retain a copy of the agreement. This form is not required to be filed with the Division and may be provided to the insurance carrier. 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 wish to consult an attorney. Texas Workers Compensation Act Texas Labor Code Section 406. 121 2 defines independent contractor as follows 1 Independent contractor means a person who contracts to perform work or provide a service for the benefit of another and who ordinarily A acts as the employer of any employee of the contractor by paying wages directing activities and performing other similar functions characteristic of an employer-employee relationship B is free to determine the manner in which the work or service is performed including the hours of labor of or method of payment to any employee C is required to furnish or have his employees if any furnish necessary tools supplies or materials to perform the work or service and D possesses the skills required for the specific work or service. .

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