Free PDF - Montana


File Size: 8.4 kB
Pages: 2
Date: January 10, 2008
File Format: PDF
State: Montana
Category: Workers Compensation
Author: ce4804
Word Count: 128 Words, 966 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://wcc.dli.mt.gov/forms/Petition-Appeal_IC_Revocation.pdf

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IN THE WORKERS' COMPENSATION COURT OF THE STATE OF MONTANA

) ) Petitioner ) ) WCC No. vs. ) ) PETITION DISPUTING ICCU ) REVOCATION OF INDEPENDENT ) CONTRACTOR EXEMPTION ) INDEPENDENT CONTRACTOR CENTRAL UNIT) Respondent. )

1. On ____________________________, I received an independent contractor exemption certificate. A copy of the certificate is attached. 2. My exemption was revoked on _______________________________. A copy of the revocation notice is attached. 3. The mediation process before the Department of Labor and Industry has been completed. ยง 39-71-415, MCA. 4. I am appealing the revocation and request the Workers' Compensation Court to determine that I am an independent contractor entitled to an independent contractor exemption. DATED this day of , 2008.

Petitioner's Signature Please print or type: Name: Street Address: City, State, Zip: Telephone #: Attach copies of application for Independent Contractor Exemption and revocation

notice