Free WCB-262 - Maine

STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION AUGUSTA, ME 043330027
TEL: 2072877071 FAX: 2072875895 TDD: 2072876119

APPLICATION FOR A CERTIFICATE OF INDEPENDENT STATUS
I, , hereby request, pursuant to 39A M.R.S.A. Secs. 105 and 401, a Certificate of Independent Status.

WOOD HARVESTER:
NAME

ADDRESS NUMBER AND STREET

CITY STATE ZIP

TELEPHONE NUMBER

Please answer each of the following questions accurately and completely. 1. (a) Do you work alone? YES_____ (b) NO_____

If the answer to Question 1(a) is NO, do you work with (Please check
appropriate box(es).)

Parent_____ Spouse_____ Sibling_____ Partner_____

Child_____ Niece_____ Nephew_____ Other (please describe)____________________

2. Please list the tools and equipment that you own and use to harvest wood.
separate sheet if necessary.)

(Attach a

3. Who is in charge of your daytoday operations?
THIS DOCUMENT MAY BE PRODUCED IN ALTERNATIVE FORMATS SUCH AS BRAILLE, LARGE PRINT AND AUDIO TAPE. WCB262(09/1999)

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4. Do you usually work for more than one landowner during the course of a year? YES_____ NO_____

5. Please describe who you have worked for during the last twelve (12) months, and how long you worked for them. (Attach a separate sheet if necessary.)

6. Please describe who you will work for during the next twelve (12) months, and how long you will work for them. (Attach a separate sheet if necessary.)

7. Please check the boxes that indicate how you are paid for harvesting wood. By the Hour_____ By the Job (in a lump sum)_____ By the Cord_____ By Board Feet_____ Other (please describe)_________________________________________

Please 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 Certificate of Independent Status shall be nullified. I further understand that the Certificate of Independent Status is based upon the information provided in this application and that any changes in these circumstances may nullify the Certificate of Independent Status. I agree to notify the Workers' Compensation Board of any subsequent changes.

_______________________________
DATE

__________________________________
SIGNATURE OF WOOD HARVESTER