Name: AugerPros Plumbing and Drain
Price range: $$$

Subcontractor Work Comp Waiver

Agreement between general contractor and subcontractor to establish independent relationship

Este formulario esta disponible en espanol en el sitio web de la Division en www.tdi.texas.gov/forms/form20numerical.html
Para obtener assistencia en espanol, llame a la Division al 800-252-7031

Part 1. Agreement

1. Type of agreementBlanket agreement

2. Estimated number of employees affected

Agreement start date *

Part 2. General Contractor Information

8. General Contractor Name: Augerpros Plumbing and Drain
9. Federal Tax ID Number: 83-2594013
10. Address: 206 W. McDermott Dr Allen, Tx 75013
11. Email: contact@augerpros.com
12. General Contractors Affirmation:
I declare that the:

subcontractor meets the qualifications of and is operating as an independent contractor under Texas Labor Code Section 406.121;
subcontractor assumes the responsibility of an employer for the performance of work; and
subcontractor's employees are not my employees for the purposes of workers' compensation insurance coverage.

Jerry Schrader - owner

Part 3. The Subcontractor Must Fill Our This Part

15. Subcontractor Name: *

16. Federal Tax ID Number

Street Address

Apartment, suite, etc

City

ZIP / Postal Code

18. Email Address

19. Subcontractors affirmation

I declare that I:

meet the qualifications of and operate as an independent contractor under Texas Labor Code Section 406.121;
assume the responsibility of an employer for the performance of work; and
my employees are not employees of the general contractor for the purposes of workers' compensation insurance coverage.

20. Signature *

21. Date of Signature *

Print Subcontractor Name