Dwc Form 85 PDF Details

DWC form 85 is an extremely important document for employers and workers in the state of California. This form is used to report injuries and illnesses that occur in the workplace, and it is critical that both employers and employees are familiar with its contents. Here we will discuss what DWC form 85 is, who needs to fill it out, and what information needs to be included. We will also provide a link to a downloadable PDF of the form so that you can reference it yourself. So let's get started!

QuestionAnswer
Form NameDwc Form 85
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesworkers compensation waiver form texas, dwc form 85 printable, dwc form 83 vs form 85, twcc 85

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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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1. It's very important to fill out the dwc texas department form properly, so be mindful while filling out the sections that contain all these fields:

Stage # 1 of completing workers compensation waiver form texas

2. Once your current task is complete, take the next step – fill out all of these fields - Signature of Subcontractor Date, Federal Tax I D Number, Address City State Zip, DWC FORM Rev, and DIVISION OF WORKERS COMPENSATION with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Step # 2 in filling out workers compensation waiver form texas

It is easy to make an error when filling out the DWC FORM Rev, for that reason make sure to go through it again before you'll submit it.

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