Independent Contractor Statement

Independent Contractor Statement

The following information must be provided on an annual basis so that CAM-Comp may make a determination as to whether an independent contractor status exists for a given policy period.
TO BE COMPLETED BY THE INDEPENDENT CONTRACTOR
Policyholder Name form is being filled out for:
Subcontractor Name:
Doing Business As (DBA):
If DBA is filed, attach a copy.
1. I operate as a :*

Sole ProprietorPartnershipCorporationLimited Liability Company
Note: If indicating Partnership, Corporation or Limited Liability Company, a Certificate of Workers’ Compensation Insurance or a properly filed Form BWC-337 must be submitted. Please contact our office.
2. The type of work I perform can be described as:
3. My federal I.D. Number is:
4. I hire employees or casual laborers to complete work for the named policyholder:

Yes Number hired (Attach Certificate of Workers’ Compensation Insurance)No Form 1040 SCHEDULE C (Profit or Loss from Business) may be provided as verification.
Number hired
5. I hire subcontractors to complete work for the named policyholder: (If yes, additional information may be required.)

YesNo
6. I have General Liability coverage: (If yes, a Certificate of General Liability Insurance is required.)

YesNo
7. To further validate my standing as an independent contractor, I state that my business has not worked exclusively for the above named insured and have worked for the following general contractors or clients during the past twelve months.
Required
1. Name

First NameLast Name
City
Phone Number

Area CodePhone Number
2. Name

First NameLast Name
City
Phone Number

Area CodePhone Number
3. Name

First NameLast Name
City
Phone Number

Area CodePhone Number
I acknowledge that as a sole proprietor, I am by law not covered by or subject to the Workers’ Disability Compensation Act.

I certify the above represents a true and complete statement of my status as an Independent Contractor. I understand a company representative may verify this statement at any time. If requested, I agree to provide documentation to verify my status as a sole proprietor.
Signature: (Independent Contractor)

Clear
Date

MonthDayYear
Date
Phone Number

Area CodePhone Number
Email
example@example.com
This form is utilized as a test of the above individual’s independent status. By completing this form, it does not automatically remove the above individual’s exposure from the audit of the policy period in question. Additional information may be required. If independent status is proven, the exposure will not be charged.
Should be Empty: