DWC Form-85 PDF Details

Navigating the complexities of worker classifications and agreements in Texas requires a keen understanding of specific documentation, notably the DWC 85 form. This crucial document serves as a formal agreement between a general contractor and a subcontractor to establish an independent relationship under the Texas Workers' Compensation Act and Texas Labor Code, Section 406.121. The form meticulously outlines the criteria classifying a subcontractor as an independent contractor, emphasizing aspects such as control over work, payroll responsibilities, and provision of tools and materials. It's instrumental in asserting that the subcontractor and their employees are not deemed employees of the general contractor, thereby delineating the responsibilities regarding workers' compensation coverage. Additionally, the form includes vital information like the term of the agreement, job site locations, and both parties' affirmation of understanding and agreement, alongside their identification details. It encapsulates the essence of a mutual declaration to uphold the independent contractor status, aiming to shield both entities from potential disputes or misclassifications. The DWC 85 form, with its detailed requirements and declarations, plays a pivotal role in the contractual relationship between general contractors and subcontractors, ensuring compliance with the state's labor laws.

QuestionAnswer
Form Name DWC Form-85
Form Length 1 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 15 sec
Other names workers compensation waiver form texas, dwc form 85 printable, dwc form 83 vs form 85, twcc 85

Form Preview Example

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.

Texas Workers' Compensation Act, Texas Labor Code, Section 406.121(2) defines "independent contractor" as follows: (1) "Independent contractor" means a person who contracts to perform

work or provide a service for the benefit of another and who ordinarily: (A) acts as the employer of any employee of the contractor by paying wages, directing activities, and performing other similar functions characteristic of an employer-employee relationship; (B) is free to determine the manner in which the work or service is performed, including the hours of labor of or method of payment to any employee; (C) is required to furnish or have his employees, if any, furnish necessary tools, supplies, or materials to perform the work or service; and (D) possesses the skills required for the specific work or service.

AGREEMENT BETWEEN GENERAL CONTRACTOR AND SUBCONTRACTOR

TO ESTABLISH INDEPENDENT RELATIONSHIP

Notice of Agreement

The undersigned General Contractor and the undersigned Subcontractor hereby declare that:

(A)the Subcontractor meets the qualifications of an Independent Contractor under Texas Workers' Compensation Act, Texas Labor Code, Section 406.121;

(B)the Subcontractor is operating as an independent contractor as that term is defined under Section 406.121 of the Act;

(C)the Subcontractor assumes the responsibilities of an employer for the performance of work; and

(D)the Subcontractor and the Subcontractor's employees are not employees of the General Contractor for purposes of the Act.

TERM (DATES) OF AGREEMENT: FROM:

TO:

Name of General Contractor

Name of Subcontractor

LOCATION OF EACH AFFECTED JOB SITE (OR STATE WHETHER

Estimated number of employees affected:___________

THIS IS A BLANKET AGREEMENT):

 

 

 

THIS AGREEMENT SHALL TAKE EFFECT NO SOONER THAN THE

 

 

DATE IT IS SIGNED.

 

 

 

 

 

 

Texas Labor Code, Texas Workers’ Compensation Act, Section 406.122 (b).

General Contractor's Affirmation

If the General Contractor's workers' compensation carrier changes

during the effective period of coverage, it is advisable for theFederal Tax I. D. Number

General Contractor to file this form with the new insurance carrier.

Signature of General Contractor

 

Date

 

 

Address (Street)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Printed Name of General Contractor

 

 

 

 

 

Address (City, State, Zip)

 

 

 

Subcontractor's Affirmation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Federal Tax I. D. Number

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Subcontractor

 

Date

 

 

 

 

 

 

 

 

Address (Street)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Printed Name of Subcontractor

 

 

 

 

 

Address (City, State, Zip)

 

 

The General Contractor should retain the original. The Subcontractor should also retain a copy of the agreement. This form may be provided to the insurance carrier.

DWC FORM-85 REV. 04/18

DIVISION OF WORKERS’ COMPENSATION

How to Edit DWC Form-85 Online for Free

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Stage # 1 of completing workers compensation waiver form texas

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