Workers Compensation Waiver of Subrogation
Please complete and sign Part 1 OR Part 2 of this document as applicable:
Part 1: My state does require me to carry worker’s compensation insurance and the insurance information is specified on my insurance certificate.
1. Signature
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Your answer
1. Title & Company
Your answer
1. Date
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Part 2: My state does not require me to carry worker’s compensation insurance.
Release and Waiver of Subrogation

As an independent contractor, it is my understanding that neither I, nor my employees, are covered by the workers’ compensation insurance policy of Nationwide Auto Transport, Inc. and/or Nationwide Auto Logistics, LLC and related entities, successors, affiliates or clients (“Companies”). I am not required by the laws of the state in which my business is located or in which I conduct business to provide workers’ compensation insurance for me or my employees and, by signing below, I hereby release and agree to defend, indemnify, and hold Companies harmless from any and all claims, demands, expenses (including reasonable attorneys’ fees) and liabilities in connection with my performance of work as an independent contractor, and I waive all subrogation rights against Companies.

In consideration for this Release, I understand that I shall not be required to provide proof of workers’ compensation insurance on myself or my employees, but I will be required to provide proof of workers’ compensation if and when I or my company meet the standards for the requirement of workers’ compensation in my state.

2. Signature
Type your full name to serve as your electronic signature
Your answer
2. Title & Company
Your answer
2. State
Your answer
2. Number of Workers
Your answer
2. Date
MM
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DD
/
YYYY
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