BONNEVILLE COUNTY
INDEPENDENT CONTRACTOR REQUEST FOR WAIVER OF WORKMAN'S
COMPENSATION AND/OR LIABILITY INSURANCE REQUIREMENTS
Contractors Name: Date:
Doing Business As:
Employer Taxpayer Identification Number or Soc. Sec. Number:
I hereby certify that I am a qualified independent contractor and that I am not required by
Idaho law to carry workman's compensation insurance. I hereby request that the Board of
County Commissioners waive the requirement for proof of workman's compensation
insurance.
I hereby request that the Board of County Commissioners waive the requirement for proof of
liability insurance for the following reasons:
______________________________________________ Date: ________________
Contractor's Signature
______________________________________________________________________
(FOR COUNTY USE ONLY!)
Requesting Department or Office:
Estimated cost of workman's compensation insurance:
Costs to be paid for by: Bonneville County Contractor
Comments:
APPROVED BY:
______________________________________________ Date: ________________
Elected Official or Department Head Signature
______________________________________________ Date: ________________
Board of County Commissioners
Rev. 4/14/2010
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome