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J:\FORMS\Templates\Administrative\Worker's Compensation Insurance Information.doc Rev 3/08 WORKER'S COMPENSATION INSURANCE INFORMATION The following worker's compensation insurance information is required for all Applicants and Contractors. One of the following items for each Applicant and Contractor must be submitted prior to working under a Public Works permit or contract. WORKERS' COMPENSATION INFORMATION: Name of Contractor/Applicant A Certificate of Consent to Self-Insure issued by the Director of Industrial Relations; OR A Certificate of Workers' Compensation Insurance Insurance Co. Policy No. Expiration Date ; OR A signed Certificate of Exemption from the Workers' Compensation laws as printed below. CERTIFICATE OF EXEMPTION I certify that in the performance of the work for this contract, I shall not employ any person in a manner so as to become subject to the Workers' Compensation Laws of California. Signed Date Title NOTICE TO APPLICANT/CONTRACTOR: If after signing this Certificate of Exemption, you should become subject to the Workers' Compensation provision of the Labor Code, you must forthwith comply with such provisions or the Permit or Contract will be cancelled or revoked.