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Get TX DWC Form 82 2018-2024

The Owner Operator should also retain a copy of the agreement. DWC FORM-82 Rev. 04/18 DIVISION OF WORKERS COMPENSATION. TEXAS DEPARTMENT OF INSURANCE DIVISION OF WORKERS COMPENSATION TDI-DWC 7551 Metro Center Drive Suite 100 Austin Texas 78744 DO NOT SEND THIS AGREEMENT TO TDI-DWC If you are not certain whether all parties meet the requirements for entering into this agreement you may wish to consult an attorney. CHECK BOX OF STATEMENT THAT APPLIES AGREEMENT BETWEEN MOTOR CARRIER AND OWNER OPERATOR TO PROVIDE WORKERS COMPENSATION INSURANCE COVERAGE AGREEMENT TO REQUIRE OWNER OPERATOR TO ACT AS EMPLOYER Notice of Declaration Notice of Agreement The undersigned Motor Carrier and the undersigned Owner Operator agree that the Motor Carrier will provide workers compensation insurance coverage to the Owner Operator and the Owner Operator s employees. The Motor Carrier will deduct will not deduct the actual premiums based on payroll that are paid or incurred by the Motor Carrier for coverage from the contract price or any other amount owed to the Owner Operator by the Motor Carrier. Owner Operator assumes the responsibilities of an employer for the performance of work. TERM DATES OF AGREEMENT FROM TO ESTIMATED NUMBER OF WORKERS AFFECTED Texas Labor Code Texas Workers Compensation Act Section 406. 123 THIS AGREEMENT SHALL TAKE EFFECT NO SOONER THAN THE DATE IT IS SIGNED. MOTOR CARRIER S AFFIRMATION If the Motor Carrier s workers compensation carrier changes during the effective period of coverage it is advisable for the Motor Carrier to file this form with the new insurance carrier. Signature of Motor Carrier Date Printed Name of Motor Carrier Federal Tax I. D. Number Address Street Address City State Zip OWNER OPERATOR S AFFIRMATION The Motor Carrier should retain the original* A legible copy of this agreement must be filed with the Motor Carrier s workers compensation insurance carrier within 10 days of the date of execution* An agreement is not considered filed if it is illegible or incomplete. TEXAS DEPARTMENT OF INSURANCE DIVISION OF WORKERS COMPENSATION TDI-DWC 7551 Metro Center Drive Suite 100 Austin Texas 78744 DO NOT SEND THIS AGREEMENT TO TDI-DWC If you are not certain whether all parties meet the requirements for entering into this agreement you may wish to consult an attorney. CHECK BOX OF STATEMENT THAT APPLIES AGREEMENT BETWEEN MOTOR CARRIER AND OWNER OPERATOR TO PROVIDE WORKERS COMPENSATION INSURANCE COVERAGE AGREEMENT TO REQUIRE OWNER OPERATOR TO ACT AS EMPLOYER Notice of Declaration Notice of Agreement The undersigned Motor Carrier and the undersigned Owner Operator agree that the Motor Carrier will provide workers compensation insurance coverage to the Owner Operator and the Owner Operator s employees. CHECK BOX OF STATEMENT THAT APPLIES AGREEMENT BETWEEN MOTOR CARRIER AND OWNER OPERATOR TO PROVIDE WORKERS COMPENSATION INSURANCE COVERAGE AGREEMENT TO REQUIRE OWNER OPERATOR TO ACT AS EMPLOYER Notice of Declaration Notice of Agreement The undersigned Motor Carrier and the undersigned Owner Operator agree that the Motor Carrier will provide workers compensation insurance coverage to the Owner Operator and the Owner Operator s employees. The Motor Carrier will deduct will not deduct the actual premiums based on payroll that are paid or incurred by the Motor Carrier for coverage from the contract price or any other amount owed to the Owner Operator by the Motor Carrier. .

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