2006 Douglas County Worker’s Compensation Form (ORS 656)

Any person who provides labor for compensation and does not qualify for an exemption is a

subject worker. Non-subject workers are defined in ORS656.027. Participant is required to

provide proof of workers’ compensation insurance or to certify that subject workers are not

employed for Ocean Festival 2006. Completion of this certificate is REQUIRED as a condition

of obtaining a special use permit for any Event that takes place at Salmon Harbor Marina. This

requirement is imposed by the Douglas County Counsel.

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Part 1

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Name: ________________________________________________________________

Mailing Address: ________________________________________________________

City, State, Zip: ________________________________________________________

Business or Organization Name: ___________________________________________

(if applicable)

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Part 2

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I, as Participant, and for the Organization, if any, named above, certify that I will not employ

workers to perform labor at Ocean Festival 2006.

___________________________________ _________________________

(Signature) (Date)

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Part 3

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Subject workers will be employed to perform labor at Ocean Festival 2006. I have

instructed my insurance agent to furnish proof of the required insurance coverage to the

Winchester Bay Merchants Association, Inc., P.O. Box 1143, Winchester Bay, OR 97467. I

understand that proof of insurance must be received prior to the Event.

_________________________________ ___________________________

(Signature) (Date)

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