Form DWC84 "Exception to Application of Joint Agreement to Affirm Independent Relationship for Certain Building and Construction Workers" - Texas

What Is Form DWC84?

This is a legal form that was released by the Texas Department of Insurance - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2018;
  • The latest edition provided by the Texas Department of Insurance;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DWC84 by clicking the link below or browse more documents and templates provided by the Texas Department of Insurance.

ADVERTISEMENT
ADVERTISEMENT

Download Form DWC84 "Exception to Application of Joint Agreement to Affirm Independent Relationship for Certain Building and Construction Workers" - Texas

Download PDF

Fill PDF online

Rate (4.7 / 5) 33 votes
TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION
7551 Metro Center Drive, Suite 100
Austin, Texas 78744
EXCEPTION TO APPLICATION OF JOINT AGREEMENT TO AFFIRM INDEPENDENT
RELATIONSHIP FOR CERTAIN BUILDING AND CONSTRUCTION WORKERS
NOTICE OF DECLARATION
The undersigned Hiring Contractor and the undersigned Independent Contractor declare that the Joint Agreement to Affirm Independent Relationship for Certain
Building and Construction Workers (as recorded on DWC FORM-83) does not apply to the subsequent hiring agreement between the Hiring Contractor and
Independent Contractor. Nothing in this declaration otherwise nullifies the Joint Agreement to Affirm Independent Relationship for Certain Building and Construction
Workers as it applies to other hiring agreements made during the term of the joint agreement.
DATE OF JOINT AGREEMENT TO AFFIRM INDEPENDENT
DATE OF SUBSEQUENT HIRING AGREEMENT TO WHICH THIS
RELATIONSHIP FOR CERTAIN BUILDING AND CONSTRUCTION
FORM APPLIES
WORKERS
LOCATION OF SPECIFIC JOB SITES NOT AFFECTED BY JOINT AGREEMENT:
NAME OF HIRING CONTRACTOR
NAME OF INDEPENDENT CONTRACTOR
Texas Labor Code, Texas Workers’ Compensation Act, Section 406.145.
Hiring Contractor’s Affirmation
If the Hiring Contractor’s workers’ compensation carrier changes
during the effective period of coverage, it is advisable for the Hiring Contractor to file
this form with the new insurance carrier.
Federal Tax I.D. Number
Signature of Hiring Contractor
Date
Address (Street)
Printed Name of Hiring Contractor
Address (City, State, Zip)
Independent Contractor’s Affirmation
Federal Tax I.D. Number
Signature of Independent Contractor
Date
Address (Street)
Printed Name of Independent Contractor
Address (City, State, Zip)
The Hiring Contractor must retain the original. A legible copy of this agreement must be filed with the hiring contractor’s workers’ compensation insurance carrier
and the division within 10 days of the date of execution. An agreement is not considered filed if it is illegible or incomplete. The Independent Contractor should also
retain a copy of the agreement.
DWC FORM-84 Rev. 04/18
DIVISION OF WORKERS’ COMPENSATION
TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION
7551 Metro Center Drive, Suite 100
Austin, Texas 78744
EXCEPTION TO APPLICATION OF JOINT AGREEMENT TO AFFIRM INDEPENDENT
RELATIONSHIP FOR CERTAIN BUILDING AND CONSTRUCTION WORKERS
NOTICE OF DECLARATION
The undersigned Hiring Contractor and the undersigned Independent Contractor declare that the Joint Agreement to Affirm Independent Relationship for Certain
Building and Construction Workers (as recorded on DWC FORM-83) does not apply to the subsequent hiring agreement between the Hiring Contractor and
Independent Contractor. Nothing in this declaration otherwise nullifies the Joint Agreement to Affirm Independent Relationship for Certain Building and Construction
Workers as it applies to other hiring agreements made during the term of the joint agreement.
DATE OF JOINT AGREEMENT TO AFFIRM INDEPENDENT
DATE OF SUBSEQUENT HIRING AGREEMENT TO WHICH THIS
RELATIONSHIP FOR CERTAIN BUILDING AND CONSTRUCTION
FORM APPLIES
WORKERS
LOCATION OF SPECIFIC JOB SITES NOT AFFECTED BY JOINT AGREEMENT:
NAME OF HIRING CONTRACTOR
NAME OF INDEPENDENT CONTRACTOR
Texas Labor Code, Texas Workers’ Compensation Act, Section 406.145.
Hiring Contractor’s Affirmation
If the Hiring Contractor’s workers’ compensation carrier changes
during the effective period of coverage, it is advisable for the Hiring Contractor to file
this form with the new insurance carrier.
Federal Tax I.D. Number
Signature of Hiring Contractor
Date
Address (Street)
Printed Name of Hiring Contractor
Address (City, State, Zip)
Independent Contractor’s Affirmation
Federal Tax I.D. Number
Signature of Independent Contractor
Date
Address (Street)
Printed Name of Independent Contractor
Address (City, State, Zip)
The Hiring Contractor must retain the original. A legible copy of this agreement must be filed with the hiring contractor’s workers’ compensation insurance carrier
and the division within 10 days of the date of execution. An agreement is not considered filed if it is illegible or incomplete. The Independent Contractor should also
retain a copy of the agreement.
DWC FORM-84 Rev. 04/18
DIVISION OF WORKERS’ COMPENSATION