TFC | Texas Facilities Commission



EXHIBIT DWORKERS’ COMPENSATION WAIVERWORKERS’ COMPENSATION WAIVERALL EMPLOYERS MUST PROVIDE EVIDENCE OF COMPLIANCE WITH THE INSURANCE REQUIREMENTS OF THE TEXAS WORKERS’ COMPENSATION ACT. Generally, an employer with one or more employees carries workers’ compensation insurance to cover those employees or elects coverage through self-insurance as permitted by Texas Labor Code, Section 406.003. Sole proprietorships who wish to perform freight services pursuant to Texas Facilities Commission’s Freight Transportation Service Provider Contract that do not carry workers’ compensation insurance must comply, agree, and attest to the following: A signed statement (see below) that the business is a sole proprietorship as defined by the Texas Workers’ Compensation Act.I am the owner of a sole proprietorship, doing business as, ______________ and am the sole employee of this business entity. I, as an individual employer, have not elected to be covered under the Texas Workers’ Compensation Act. I, and the sole proprietorship that I represent, am covered by medical insurance that will be used to cover any injuries obtained in providing freight services to Texas Facilities Commission (TFC).I, and the sole proprietorship that I represent, waive all rights to sue the Texas Facilities Commission or its officers, employees, or commissioners or the State of Texas for injuries not caused by its negligence.I, and the sole proprietorship that I represent, release liability of the Texas Facilities Commission or its officers, employees, or commissioners or the State of Texas for any injuries to myself in the course of performing work in conjunction with providing freight services to TFC.BUSINESS NAME: ______________________________________________________________________SIGNATURE OF SOLE PROPRIETOR: ___________________________________________ Date ____________ ................
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