City of Santa Barbara
Request for Waiver
Workers’ Compensation Insurance Requirement
City Information
Department/Division:
Point of Contact:
Contract/PSA/Bid Reference #:
Will any work be performed on City Property?
Nature of Work to Be Performed:
Business Information
Legal Business Name of Contractor/Vendor:
Contractor/Vendor Point of Contact Name:
Contractor/Vendor Point of Contact Telephone #:
Business Address:
Business Legal Form:
Declaration:
With respect to the above-mentioned business, I hereby warrant that the business has no employees other
than the owners, officers, directors, partners or other principals who have elected to be exempt from
Worker's Compensation coverage in accordance with California law. I further warrant that I understand the
requirements of Section 3700 et seq. of the California Labor Code with respect to providing Worker's
Compensation coverage for any employees of the above mentioned business. I agree to comply with the
code requirements and all other applicable laws and regulations regarding workers compensation, payroll
taxes, FICA and tax withholding and similar employment issues. I further agree to hold the City of Santa
Barbara, its Council, officers, officials, employees, agents, volunteers, and consultants harmless from and
against any and all liability, loss, damage, claims, causes of action, demands, charges, fines, costs, and
expenses which may arise from the failure of the above-mentioned business to comply with any such laws
or regulations. I therefore request that the City of Santa Barbara waive its requirement for evidence of
Workers' Compensation insurance in connection with the above-referenced work.
Signature
Owner, Officer, Director, Partnership, or other Principal
Title
Date
click to sign
signature
click to edit
![]()
