Free WCB-260 - Maine

APPLICATION FOR PREDETERMINATION OF INDEPENDENT CONTRACTOR STATUS TO ESTABLISH CONCLUSIVE PRESUMPTION
STATE OF MAINE Workers' Compensation Board 27 STATE HOUSE STATION AUGUSTA, ME 043330027
TEL: (207) 2877071 FAX: (207) 2875895 TDD: (207) 2876119

LANDOWNER
NAME

LANDOWNER'S AGENT (IF APPLICABLE):
NAME

ADDRESS NUMBER AND STREET

ADDRESS NUMBER AND STREET

CITY STATE ZIP

CITY STATE ZIP

TELEPHONE NUMBER

TELEPHONE NUMBER

I, ______________________________________________(landowner or landowner's agent), hereby request a predetermination pursuant to 39A M.R.S.A. §§ 105 and 401 that the relationship between the abovenamed landowner and the following individual or company is that of landowner/independent contractor within the definitions contained in 39A M.R.S.A. §§ 102(13) and 401(4).

WOOD HARVESTER

NAME

ADDRESS NUMBER AND STREET

CITY STATE ZIP

TELEPHONE NUMBER

THIS DOCUMENT MAY BE PRODUCED IN ALTERNATIVE FORMATS SUCH AS BRAILLE, LARGE PRINT AND AUDIO TAPE. WCB260(9/96)

(1)

Answer each of the following questions accurately and completely. 1. (a) Have you enclosed a copy of the wood harvesting contract? YES _____ (b) NO _____

If applicable, have you enclosed a copy of the contract, between the landowner and the landowner's agent, that establishes an agency relationship? YES _____ NO _____

2.

Does the wood harvester employ assistants to help in executing the contract? YES _____ NO _____

If no, does the wood harvester have the authority to hire such assistants? YES _____ 3. NO _____

Does the wood harvesting contract expressly state that the independent contractor will not hire any employees to assist in the wood harvesting without first providing a certificate of insurance to the landowner showing that the independent contractor has obtained the required coverage for independent contractor's employees? YES _____ NO _____

4.

(a)

Which party supplies the tools and equipment that is needed to perform the work?

LANDOWNER ____WOOD HARVESTER ____ OTHER (PLEASE SPECIFY)__________ (b) What tools are supplied?

5.

Who has control over the daytoday operation of the work?

6. What is the duration of the agreement to perform work? (If there is no specific term or duration to the contract, describe how the contract can be terminated.)

(2) 7. Will the wood harvester be performing the same type of work for other landowners while completing this contract? YES _____ If yes, please describe: NO _____

8. What are the terms of payment? (That is, is the wood harvester paid a specific sum of money, by the hour, by the amount of wood cut, or by some other method?)

9. Does the landowner make withholdings from the payments made to the wood harvester for social security, income taxes, unemployment or any type of insurance? YES _____ If yes, please explain: NO _____

Read carefully and sign below: I hereby certify that the foregoing information is truthful and accurate. I understand that should any information contained in this application be found to be intentionally misleading or fraudulent, the predetermination of independent contractor status shall be nullified. I further understand that this predetermination of independent contractor status is based upon the information provided in this application and that any changes in these circumstances may nullify the predetermination of independent contractor status. I agree to notify the Workers' Compensation Board of any subsequent changes.

SIGNATURE OF LANDOWNER/AGENT

DATE

SIGNATURE OF WOOD HARVESTER

DATE