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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 ICCU DETERMINATION (NON-WORKERS' COMPENSATION)

1. On _______________________, I applied for an independent contractor exemption. A copy of my application is attached. 2. My request for the independent contractor exemption certificate was denied on ____________________. A copy of the denial is attached. 3. The mediation process before the Department of Labor and Industry has been completed. § 39-71-415, MCA. 4. I am appealing the denial 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.

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

Attach copies of Independent Contractor Exemption and denial letter