Full Name

    Company Name (if applicable)
    (Legal Company Name - Must Match W9)



    Security/Investigations License(s) with State, Number and Expiration Date. (If none leave blank)

    Understanding of Worker's Compensation Requirement (if applicable) (Yes/No)
    The Contractor understands that the Company requires all independent contractors to have their own Worker's Compensation coverage and if they do not provide a certificate as instructed or the certificate is invalid or expired, the Company may withhold 3% of gross payments.

    Please upload your company license(s) if applicable
    Please label "Company (State) License - NAME"

    Please upload your general liability insurance certificate (if applicable) (GL and WC are required for companies)
    Please label "GL - NAME"

    Please upload your worker's comp insurance certificate (if applicable) (GL and WC are required for companies)
    Please label "WC - NAME"

    Signature (must be legible and match name above)
    "My signature below confirms my agreement to the terms presented and to the temporary, 'at-will' independent contractor relationship between myself (the Independent Contractor) and LaSorsa & Associates; I am to receive payment up to 60 days post invoice upon project completion with approved expenses reimbursed; I must provide my own personal equipment; I have no claim to benefits such as sick or vacation pay or leave, worker’s compensation, health or disability benefits, unemployment insurance benefits, or employee benefits of any kind; I am subject to IRS Form 1099 and I must provide a W-9; I will indemnify and hold-harmless LaSorsa & Associates and its affiliates, officers, directors, employees, agents, successors and assigns from and against all losses, damages, liabilities, deficiencies, actions, judgments, interest, awards, penalties, fines, costs, or expenses of whatever kind, including reasonable attorneys' fees, arising out of or resulting from bodily injury, death or damage to real or tangible personal property resulting from acts or omissions as well as any breach of any representation, warranty or obligation under this Agreement; I accept the choice of law for any discrepancy, settlement or otherwise is the state of Florida."