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Resolution No. 2008-63
ATTACHMENT #7
CITY OF HUNTINGTON BEACH
2000 Main Street, Huntington Beach, CA 92648-2702
Declaration of Non-Employer Status
The State of California requires every enterprise or business to provide workers
compensation insurance coverage. If you have no employees, you may make a
declaration to that effect by completing and signing this form and returning to:
City of Huntington Beach
2000 Main Street
Huntington Beach, CA 92648-2702
I certify that in the performance of the activity or work for which this permit is
issued, I shall not employ any person in any manner so as to become subject to
California Workers’ Compensation Insurance requirements.
I authorize the City of Huntington Beach to immediately and retroactively
revoke the license or permit issued under this declaration if I hire any
employee(s) or become subject to the provision of the laws requiring Workers’
Compensation Insurance.
Company / Organization: _______________________________________________
Address: ___________________________________________________________
Applicant [please print]: ________________________________________________
Title, if any: ________________________________________________________
Applicant’s Signature: ___________________________________________________
Date Signed: ________________________________________________________
Telephone Number: ____________________________________________________

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Declaration of non employee status-electronic fillable form

  • 1. Resolution No. 2008-63 ATTACHMENT #7 CITY OF HUNTINGTON BEACH 2000 Main Street, Huntington Beach, CA 92648-2702 Declaration of Non-Employer Status The State of California requires every enterprise or business to provide workers compensation insurance coverage. If you have no employees, you may make a declaration to that effect by completing and signing this form and returning to: City of Huntington Beach 2000 Main Street Huntington Beach, CA 92648-2702 I certify that in the performance of the activity or work for which this permit is issued, I shall not employ any person in any manner so as to become subject to California Workers’ Compensation Insurance requirements. I authorize the City of Huntington Beach to immediately and retroactively revoke the license or permit issued under this declaration if I hire any employee(s) or become subject to the provision of the laws requiring Workers’ Compensation Insurance. Company / Organization: _______________________________________________ Address: ___________________________________________________________ Applicant [please print]: ________________________________________________ Title, if any: ________________________________________________________ Applicant’s Signature: ___________________________________________________ Date Signed: ________________________________________________________ Telephone Number: ____________________________________________________