HomeMy Public PortalAboutWC Waiver-Non-construction contractorsTOWN OF GULF STREAM
PALM BEACH COUNTY, FLORIDA
COMMISSIONERS
SCOTT MORGAN, Mayor
THOMAS M. STANLEY, Vice-Mayor
PAUL A. LYONS, JR.
JOAN K. ORTHWEIN
THOMAS A. SMITH
Telephone
(561)276-5116
Fax
(561) 448-1009
Town Manager
Gregory L. Dunham
Town Clerk
Renee Basel
I, ________________________________________________swear (affirm) that the company listed below is
engaged in an industry other than construction and has less than four (4) employees and is therefore not required to
obtain Workers' Compensation Insurance by State Law.
Signature
Company Name Date
Address
City and State
STATE OF _____________ COUNTY OF ______________
The foregoing instrument was acknowledged before me this ______________ day of ____________, 20___, by
_______________________________________________________.
_____________________________________________ Signature of Notary Public – State of Florida
_____________________________________________ Print, Type, or Stamp Name of Notary Public Personally
Known _________ OR Produced Identification ________
Type of Identification Produced: _____________________________