Orange County Public Schools Independent Contractor Request for Waiver of General Liability Insurance
___________________________________, acting as an Independent Contractor providing ________________________________services to _______________________________ requests a waiver of the General Liability Insurance required by the Independent Contractor agreement entered with Orange County Public Schools. The justification for a waiver of this requirement is based on the following: No Risk involved with providing service (explain) Frequency of the service (explain)
IC is not a Corporation, LLC or registered business with the State and insurance is cost-prohibitive Explain below, in detail, your basis for this justification including any risks involved:
Certification:
_____________________________ (Independent Contractor) shall indemnify, hold harmless, assume liability for, and for, and defend Orange County Public Schools, its member associations, employees, officers, agents and volunteers from any and all damages, awards, costs and expenses including, but not limited to, attorney’s fees, court costs, and all other sums which the district and its employees, officers, claim or action founded thereon, arising or alleged to have arisen out of the sanction issued by OCPS, or by any action or omission by Independent Contractor, its members, agents, employees, volunteers, officers, or directors in relation to the sanctioned event. Authorized Signature ____________________________
Independent Contractor
Address _______________________________ City, St, Zip ____________________________ Date _________________________________
Printed ______________________________ Title _____________________________
Affidavit
State of________________, County of _______________
Before me personally appeared ____________________________who says that he/she executed the above instrument of his/her own free will and accord, with full knowledge of the purpose therefore. Sworn and subscribed in my presence this ____day of ___________, _____. My commission expires on __________________________, ______. ____________________________ Notary Public Personally Known - or - Produced Identification Type of Identification Produced ___________________________________________________________________
RETURN THIS FORM TO PROCUREMENT SERVICES DEPARTMENT
OCPS1037Pro (Revised 10/07)