Free PDF - Montana


File Size: 7.8 kB
Pages: 1
Date: January 10, 2008
File Format: PDF
State: Montana
Category: Workers Compensation
Author: ce4804
Word Count: 114 Words, 865 Characters
Page Size: Letter (8 1/2" x 11")
URL

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

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IN THE WORKERS' COMPENSATION COURT OF THE STATE OF MONTANA ) ) ) Petitioner ) ) vs. ) ) ) ) ) ) INDEPENDENT CONTRACTOR CENTRAL UNIT) Respondent. )

WCC No. PETITION DISPUTING INDEPENDENT CONTRACTOR DETERMINATION (NON-WORKERS' COMPENSATION)

1. I am appealing the Determination of the Independent Contractor Central Unit dated ________________________________, 2008. A copy of the Determination is attached. 2. The mediation process before the Department of Labor and Industry has been completed. ยง 39-71-415, MCA. 3. I am appealing the Determination and request the Workers' Compensation Court to reverse the Determination of the Independent Contractor Central Unit. DATED this day of , 2008.

Signature of Petitioner Please print or type: Name: Street Address: City, State, Zip: Telephone #:

Attach copy of the Independent Contractor Central Unit Determination