TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION
7551 Metro Center Drive, Suite 100
Austin, Texas 78744
If you are not certain whether all parties meet the requirement for entering into this agreement, you may wish to consult an attorney.


AGREEMENT BETWEEN GENERAL CONTRACTOR AND SUBCONTRACTOR
TO PROVIDE WORKERS' COMPENSATION INSURANCE

Notice of Agreement

The undersigned General Contractor and the undersigned Subcontractor hereby agree that the General Contractor ○ will withhold  ● will not withhold the cost of workers' compensation insurance coverage from the Subcontractor's contract price and that, for the purpose of providing workers' compensation insurance coverage, the General Contractor will be the employer of the Subcontractor and the Subcontractor's employees. This agreement makes the General Contractor the employer of the Subcontractor and the Subcontractor's employees only for the purpose of workers' compensation laws of Texas and for no other purpose.

TERM (DATES) OF AGREEMENT:

FROM : Blanket Agreement

TO : Blanket Agreement

LOCATION OF EACH AFFECTED JOB SITE (OR STATE WHETHER THIS IS A BLANKET AGREEMENT) : Blanket Agreement

ESTIMATED NUMBER OF EMPLOYEES AFFECTED : 1


THIS AGREEMENT SHALL TAKE EFFECT NO SOONER THAN THE DATE IT IS SIGNED.
Texas Labor Code, Texas Workers' Compensation Act, Section 406.123

General Contractor's Affirmation

If the General Contractor's workers' compensation carrier changes during the effective period of coverage, it is advisable for the General Contractor to file this for with the new insurance carrier.

Federal Tax I.D Number : 01-0813083

Signature of General Contractor :




Printed Name of General Contractor : Upstream International, LLC

Address (Street) : 15140 Southwest Fwy, Suite C

Address (City, State, Zip) : Sugar Land, TX 77478

Subcontractor's Affirmation

Signature of Subcontractor :




The General Contractor should retain the original. Legible copies of this agreement should be filed with the general contractor's workers' compensation insurance carrier and the Division within 10 days of execution. If the General Contractor is certified self-insured, a copy should be filed with the Division's Self-Insurance Regulation service area. An agreement is not considered filed if it is illegible or incomplete. Filing may be accomplished by mail or facsimile transmission. The Subcontractor must also retain a copy of the agreement.

Division Date Stamp Here :