Full Text
ENGINEERING DIVISION 8101 RALSTON RD. ARVADA, CO 80002 www.arvada.org [EMAIL REDACTED] [PHONE REDACTED] CERTIFICATE OF EXEMPTION FROM STATUTORY WORKMEN’S COMPENSATION This is to certify to the City of Arvada that (contractor) is exempt from the provisions of the Colorado Workmen's Compensation Act for the following reason: The contractor is a sole proprietor or working general partner (circle one) as contemplated in Section 8-40-302(5)(b) and does not employ any person or persons in any business for which an Arvada Municipal Contractor's License is required. If the contractor subsequently employs any person or persons to perform work in the City of Arvada, the contractor agrees to provide the City with a Certificate of Insurance indicating proof of statutory workmen's compensation coverage on these individuals prior to their start of work in Arvada. DATE CONTRACTOR DBA: NAME OF BUSINESS Workmen's Comp Exemption Form.doc