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    Affidavit of Exempt Status Under The Workers' Compensation Act

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    Arlyn Jane Pingol
    Alfonso U. Dantes II has submitted an affidavit stating that as a volunteer teacher at Diffun National High School, he is not an employee and is exempt from workers' compensation. He understands that by signing the affidavit, he is establishing that he is an independent contractor not eligible for workers' compensation benefits. He also acknowledges that signing the affidavit does not affect the rights or coverage of any actual employees. The affidavit was signed and notarized on June 4, 2018 in Diffun, Quirino.

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    Affidavit of Exempt Status Under The Workers' Compensation Act

    Uploaded by

    Arlyn Jane Pingol
    87 views2 pages
    Alfonso U. Dantes II has submitted an affidavit stating that as a volunteer teacher at Diffun National High School, he is not an employee and is exempt from workers' compensation. He understands that by signing the affidavit, he is establishing that he is an independent contractor not eligible for workers' compensation benefits. He also acknowledges that signing the affidavit does not affect the rights or coverage of any actual employees. The affidavit was signed and notarized on June 4, 2018 in Diffun, Quirino.

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    affidavit of compensation

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    affidavit

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    Alfonso U. Dantes II has submitted an affidavit stating that as a volunteer teacher at Diffun National High School, he is not an employee and is exempt from workers' compensation. He understands that by signing the affidavit, he is establishing that he is an independent contractor not eligible for workers' compensation benefits. He also acknowledges that signing the affidavit does not affect the rights or coverage of any actual employees. The affidavit was signed and notarized on June 4, 2018 in Diffun, Quirino.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    87 views2 pages

    Affidavit of Exempt Status Under The Workers' Compensation Act

    Uploaded by

    Arlyn Jane Pingol
    Alfonso U. Dantes II has submitted an affidavit stating that as a volunteer teacher at Diffun National High School, he is not an employee and is exempt from workers' compensation. He understands that by signing the affidavit, he is establishing that he is an independent contractor not eligible for workers' compensation benefits. He also acknowledges that signing the affidavit does not affect the rights or coverage of any actual employees. The affidavit was signed and notarized on June 4, 2018 in Diffun, Quirino.

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    © All Rights Reserved
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    of 2

    REPUBLIC OF THE PHILIPPINES )

    MUNICIPALITY OF Diffun ) S.S.


    x-------------------------------------------------------x

    AFFIDAVIT OF EXEMPT STATUS UNDER THE WORKERS’


    COMPENSATION ACT
    I, ALFONSO U. DANTES II state under oath as follows:

    1. I, ALFONSO U. DANTES II is operating as Volunteer Teacher in Diffun National High School without
    compensation;

    2. I understand that based upon the representations in this Affidavit of Exempt Status, I am requesting Diffun
    National High school to consider my business to be that of an independent contractor; that I am not an
    employee under the Workers’ Compensation Act and the policy issued by Diffun National High School ;
    and that no premium be charged for the services performed by my business during the policy year;

    3. I am an independent contractor, not an employee of the contractor. I do not want workers’


    compensation insurance and understand that I am not eligible for Workers’ Compensation benefits;

    4. I will obtain workers’ compensation and employers’ liability insurance for my employees if I have employees,
    unless they are otherwise exempt from the requirements of the Workers’ Compensation Act;

    5. I have read, signed and attached the Exempt Status Fact Sheet describing what is an Independent
    Contractor and the information provided is not the result of force, threats, coercion, compulsion or duress;

    6. I understand that the execution of the affidavit shall establish a rebuttable presumption that the executor is
    not an employee for purposes of the Workers’ Compensation Act;

    7. I understand that the execution of an affidavit shall not affect the rights or coverage of any employee of the
    individual executing the affidavit.

    IN WITNESS WHEREOF, we have hereunto set our hands this 4th day of June, 2018 at Diffun, Quirino.

    ALFONSO U. DANTES II
    Affiant

    SUBSCRIBED AND SWORN to before me in the Municipality of Diffun this 4th day of
    June, 2018.

    Atty. MA. KAREN A. BALDONADO-GUILLERMO


    Notary Public
    Until December 31, 2019
    Doc. No. 496; PTR No. 3218465/ 01-03-2018
    Page No. 101 ; Lifetime IBP No. 17396/05-20-2017
    Book No. 03; ROLL No. 67812/05-26-2017
    Series of 2018. (MCLE Governing Board Order No. s-2008)
    Diffun, Quirino

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