HomeMy WebLinkAboutBARRY SHAPIRO LLC - CONTRACT - AGREEMENT MISC - BARRY SHAPIROCERTIFICATE OF EXEMPTION FROM STATUTORY WORKERS’ COMPENSATION LAW
AND ACKNOWLEDGEMENT OF RISK/HOLD HARMLESS AGREEMENT
I, Barry Shapiro, as an owner in Barry Shapiro LLC, a Limited Liability Company, certify to the
City of Fort Collins, Colorado (the “City”) that the aforementioned business has no employees
as defined by the Workers’ Compensation Act of Colorado, C.R.S. §§ 8-40-101, et seq., (the
“Act”) other than those owners, members, partners, directors or other principals that have
elected to be exempt from Workers’ Compensation coverage in accordance with Colorado law.
On behalf of said business and its officers, agents, insurers, heirs, legal representatives,
successors and assigns (collectively the “Business”), I warrant that I have full authority to
execute this Exhibit on behalf of the Business. I warrant I understand the requirements of the
Act with respect to providing Workers’ Compensation coverage for any employees of the
Business. If the Business’s status changes in such a manner that requires Workers’
Compensation Insurance, the Business shall provide the City with a Certificate of Insurance
evidencing proof of Workers’ Compensation Insurance coverage and Employer’s Liability
Insurance coverage as required by the Agreement. The Business shall provide such
Certificate of Insurance prior to the employees’ start of work for the City.
On behalf of the Business, I acknowledge the Business may be contracting to engage in
activities that involve a risk of personal injury, that the Business is capable of performing the
activities, and that the Business shall take all necessary precautions to prevent injury. The
Business does hereby waive, release and forever discharge and hold harmless the City, its
officers, employees, agents and insurers from any and all liability, damages, claims, causes of
action and demands with respect to any bodily injury, personal injury, illness, or death that
may result from the performance of the Agreement, either in law or equity, whether caused by
the negligence or breach of contract of the City its officers, employees, agents and insurers or
otherwise. The Business also understands that the City, its officers, employees, agents and
insurers do not assume any responsibility for, or obligation to, provide the Business with
financial assistance or other assistance, including but not limited to medical, health, or
disability insurance in the event of any bodily injury, personal injury, illness or death The
Business agrees to defend, indemnify, and hold harmless the City from any and all such
claims.
As an independent contractor, the Business acknowledges that neither the Business nor any
person employed by or serving the Business is entitled to workers’ compensation benefits
from the City. The Business hereby waives any rights or claims to workers’ compensation
benefits from the City, and agrees to indemnify and hold the City harmless against any claims
for such benefits by any officer, director, owner, employee, or servant of the Business or any
other person claiming through the Business. By signing this Certificate, the Business
acknowledges that it is responsible and liable for all work-related injuries, and further requests
the City waive its requirement for evidence of Workers’ Compensation Insurance.
Business: Barry Shapiro LLC
By:
Printed: Barry Shapiro
Title: President/Founder
Date:
DocuSign Envelope ID: E9C77097-4426-4B12-BEF4-A377B224A98B
3/4/2017