I have agreed to provide services to Alltech Professional Services, Inc as an Independent Contractor, not a Alltech Professional Services, Inc employee. I understand that as an Independent Contractor, I have been engaged to perform certain services according to my own manner and method, free from Alltech Professional Services, Inc direct intervention in matters connected with the performance of the services, except as to the result or product of the work.

I hereby declare that I have willfully elected, as allowed by State law, to be exempt from Workers’ Compensation Law for myself and/or my employee(s). By my decision to file a certificate of election, I understand that I may not recover benefits or compensation from my state or from Alltech Professional Services, Inc.


1. For good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, I hereby RELEASE, WAIVE, DISCHARGE AND CONVENANT NOT TO SUE Alltech Professional Services, Inc ., their officers, servants, agents, and employees (hereinafter referred to as RELEASEES) from any and all workers’ compensation claims whatsoever arising out of or related to any loss, damage, or injury, including death.

2. I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS THE RELEASEES from any claims, including court costs and attorney’s fees that may be incurred due to my loss.

3. It is my express intent that this Release and Hold Harmless Agreement shall bind the members of my family and spouse (if any), if I am alive, and my heirs, assigns and personal representative, if I am not alive, shall be deemed as a RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE the above named RELEASEES for Workers’ Compensation claims.

IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT that I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate and complete consideration fully intending to be bound by same.

IN WITNESS WHEREOF, I have hereunto set my hand:
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