This affidavit certifies that the above named person is an independent contractor as defined by the indicated provisions of law, that the above named person has worker’s compensation insurance or is a qualified self-insurer as to any and all employees in their hire, and that the above named person desires to be exempt from worker’s compensation coverage and forgoes the right of recovery under the Worker’s Compensation Act from anyone for whom this person works as an independent contractor. This affidavit is binding and holds harmless any person and their worker’s compensation insurance carrier contracting with the above named person (as an independent contractor) and their worker’s compensation insurance carrier. This affidavit is valid for one year from the date of issue.