Free WCB-261 - Maine

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

APPLICANT:

NAME

ADDRESS NUMBER AND STREET

CITY STATE ZIP

TELEPHONE NUMBER

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

POTENTIAL INDEPENDENT CONTRACTOR

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. WCB261(3/97)

(1)

1. Please indicate the type of agreement that exists between the Applicant and the Potential Independent Contractor. Written contract _____ (Please attach a copy of the signed contract, and answer the questions that follow.) Verbal agreement _____ (Please describe the agreement, and answer the questions that follow).

2.

How long will the contract or agreement be in effect?

3.

How can the contract or agreement be terminated or discontinued?

4.

How will the Potential Independent Contractor be paid? (For example, will the Potential Independent Contractor be paid by the hour, or is there a set amount that the Potential Independent Contractor will be paid for completing the contract?)

5.

Will the Potential Independent Contractor employ assistants to help complete the contract or agreement?

YES _____

NO _____

If "NO", can the Potential Independent Contractor employ assistants to help complete the contract or agreement? YES _____ NO _____

(2)

6. Will the Applicant supply any of the tools and equipment necessary to perform the work?

YES _____

NO _____

If "YES", what tools and/or equipment will the Applicant supply?:

7.

Will the Potential Independent Contractor supply any of the tools and equipment necessary to perform the work?

YES _____

NO _____

If "YES", what tools and/or equipment will the Potential Independent Contractor supply?:

8. Who decides how the work is done from daytoday? (In other words, does the Applicant or the Potential Independent Contractor have the right to decide such things as what work is to be done from daytoday, the hours between which the work is to be performed, and how best to perform the work?)

_____ APPLICANT

_____ POTENTIAL INDEPENDENT CONTRACTOR

9. Please describe the nature of the Applicant's business.

10. Please describe the nature of the Potential Independent Contractor's business.

(3)

11. Has the Potential Independent Contractor entered into similar contracts or agreements with other individuals which will be performed at the same time?

YES _____

NO _____

(a) If "YES", please describe the similar agreements.

(b) If "NO", does the Potential Independent Contractor have the right to enter into similar agreements which will be performed at the same time? YES _____ NO _____

12. Will the Applicant make withholdings from payments made to the Potential Independent Contractor for social security, income taxes, unemployment, or any type of insurance?

YES _____

NO _____

If "YES", please describe what withholdings will be made by the Applicant.

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 APPLICANT

DATE

SIGNATURE OF POTENTIAL INDEPENDENT CONTRACTOR

DATE