CONTRACTORS STATE LICENSE BOARD
9821 Business Park Drive, Sacramento, CA 95827
STATE OF CALIFORNIA
Mailing Address: P.O. Box 26000, Sacramento, CA 95826
Arnold Schwarzenegger, Governor
13L-50 (rev. 09/05)
Exemption from Workers’ Compensation – Page 1 of 1
Exemption from Workers’ Compensation
Before the Contractors State License Board (CSLB) can issue a new license or reinstate, reactivate, or renew an existing license, the applicant
or licensee must have on file a Certificate of Workers’ Compensation Insurance or a Certificate of Self-Insurance issued by the Director of
Industrial Relations, or must obtain an exemption by completing and submitting these forms.
To be exempt from workers’ compensation, an applicant or licensee must submit this form to CSLB, certifying under penalty of perjury that
he or she does not employ anyone in a manner that is subject to the workers’ compensation laws of California. (See Business and Professions
Code Section 7125.)
DO NOT SUBMIT THIS FORM IF:
You have an inactive license.
The license qualifier is a Responsible Managing Employee (RME).
You have employees.
For exemption from workers’ compensation, you must complete the requested information, check only one of the boxes, and sign the form.
Please type or print neatly and legibly in black or dark blue ink.
SECTION 1 – BUSINESS NAME AND ADDRESS
FULL BUSINESS NAME (as it appears on the license)
CSLB LICENSE OR APPLICATION FEE NUMBER
BUSINESS MAILING ADDRESS number/street or P.O. box
BUSINESS STREET ADDRESS number/street only – NO P.O. boxes
BUSINESS PHONE NUMBER
BUSINESS FAX NUMBER
BUSINESS E-MAIL ADDRESS
□ CHECK THIS BOX IF THE ABOVE ADDRESS IS NEW.
SECTION 2 – REQUIRED CHECK BOX
YOU MUST CHECK ONLY ONE OF THE BOXES BELOW.
I do not employ anyone in the manner subject to the workers’ compensation law