Form - DWC083
Part 1. Agreements: Check only one:
Joint agreement to affirm independent relationship for certain building and construction workers.
Agreement to establish employer employee relationship for certain building and construction workers (Complete items 1-7 as appropriate.)pe option 2
1. Type of Agreement
Blanket agreement
Job-site specific agreement
2. Agreement start date (mm/dd/yyyy)
/
Month
/
Day
Year
Date
3. Agreement end date (mm/dd/yyyy)
/
Month
/
Day
Year
Date
4. Estimated number of employees affected
5. Location covered: Address (street or PO box, city, state, ZIP code)
6. Location covered: Address (street or PO box, city, state, ZIP code)
7. Location covered: Address (street or PO box, city, state, ZIP code)
8. Hiring contractor name
9. Federal Tax ID number
10. Address (street or PO box, city, state, ZIP code)
11. E-mail
example@example.com
12. Hiring contractor's affirmations - Check only one:
Joint agreement to affirm independent relationship for certain building and construction sites
Agreement to establish employer-employee relationship for certain building and construction workers
Check One:
will withhold the cost of workers' compensation insurance
will not withhold the cost of workers compensation insurance
13. Signature of hiring contractor
*
Part
3
.
The
independent contractor
must complete this part.
15. Independent contractor name
16. Federal tax ID number
17. Address (street or PO box, city, state, ZIP code)
18. Signer's E-mail
*
example@example.com
Check only one:
Joint agreement to affirm independent relationship for certain building and construction workers
Agreement to establish employer employee relationship for certain building and construction workers
20. Signature of independent contractor
*
21. Date of signature (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Preview PDF
Submit
Should be Empty: