Provider Compliance & Attestation Form

Welcome to your Provider Compliance & Attestation Form

Name

Organization/Company

email address

My business is a legally registered entity (e.g., LLC, Corporation, Sole Proprietorship with a valid EIN/Tax ID) in good standing within the jurisdiction(s) where I operate.

I operate as an independent contractor, retaining sole control over the methods, schedule, and tools used to perform the services. I maintain multiple clients and am not an employee, partner, or joint venturer of The Guidant Network.

I am solely responsible for paying all federal, state, and local taxes, withholding, and worker's compensation obligations associated with my business and any personnel I employ.

I hold all necessary federal, state, and municipal licenses, permits, and professional certifications required to legally perform the contracted services.

Neither I nor my business entity is currently debarred, suspended, or subject to any regulatory enforcement actions, and I have no pending litigation or material claims regarding professional negligence or breach of contract.

I maintain adequate commercial insurance coverage appropriate for my industry, including General Liability insurance (and Professional Liability/Errors & Omissions, if applicable).

I understand that The Guidant Network requires me to maintain my own insurance coverage, and I agree to provide a Certificate of Insurance (COI) naming The Guidant Network as an additional insured upon request.

I certify that the statements above are true, accurate, and complete. I understand that The Guidant Network is relying on these representations in entering into a business relationship with me. I agree to immediately notify The Guidant Network in writing if any of these attestations change during the course of our engagement.

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Provider Compliance & Attestation Form

The Guidant Path Series & Other Books By Stephen L Kent