Affidavit Of Exempt Status Under Worker Compensation

EXEMPT STATUS FACT SHEET

An independent contractor is defined by law as one who engages to perform certain services for another, according to

his own manner, method, free from control and direction of his contractor in all matters connected with the performance

of the service, except as to the result or product of the work.

Below are statements to help you decide if you are an independent contractor. No one statement is controlling,

and your status is based on all the facts in your situation. If a statement describes your situation, then check

the box. If at least six of the statements below do not describe your business, you should not sign the attached

Affidavit of Exempt Status Under the Workers’ Compensation Act.

1. The nature of the contract between you and the contractor shows you are independent from the contractor. For

example: Is there a written contract where you agree that you are an independent contractor? Are you a corporation

or limited liability company? Do you maintain commercial general liability insurance or other business insurance?

2. The contractor exercises very little control over your work. For example: By the agreement, can the contractor

exercise control on the details of the work or your independence? Do you exercise control over most of the details of

the work? Do you create plans or specifications for the job? Do you set your own work hours?

3. You are engaged in a distinct occupation or business for others. For example: Do you work for companies or

individuals other than the Contractor? Do you work for competitors of the Contractor? Does your business have a

logo or uniform?

4. Your job is the kind of occupation where the work is usually performed by a specialist without supervision, and

not under the direction of the contractor. For example: Is your work supervised by the Contractor?

5. Your occupation requires special skills, license, education or training.

6. The contractor does not supply the things needed to perform your job such as the tools and the place of work.

For example: Do you supply any of the materials or tools for the work? Do you operate a vehicle owned by the

contractor? Was the work performed at your business or the contractor’s business location or jobsite?

Do you

wear a uniform supplied by the contractor?

7. The length of the job and how long you have worked for the Contractor does not show that you are really an

employee. For example: Is this a one-time job, or will you be doing this for the contractor regularly?

8. You are paid as a separate contractor, not as an employee. For example: Do you invoice the Contractor for

your services? Are you paid by the job? Do you file a federal income tax return for your business? Do you expect

to receive an IRS Form 1099 from the Contractor? Does the Contractor pay your expenses?

9. Your work is not the regular business of the employer. For example: Is your work customarily done in the

Contractor’s line of business or as part of the Contractor’s daily work? Have you ever been an employee of the

Contractor? Do you work with other people hired by the Contractor on the work you perform?

10. You do not consider yourself an employee of the contractor. For example: Will the Contractor withhold taxes or

monies from your payment? Have you ever been an employee of the Contractor? Have you or your employees

ever filed an insurance claim against the Contractor?

11. You do not have the right to terminate the relationship without liability. For example: If you quit before the job is

finished, is there a penalty?

Based upon these factors, do you believe that you are an independent contractor with exempt status?

__________________________

Signature____________________________

(WRITE YES OR NO)

(INDEPENDENT CONTRACTOR/EXECUTOR)

Note: Employers who knowingly and willfully require an employee or subcontractor to execute an affidavit

when the employer knows that the employee or subcontractor is required to be covered under a workers’

compensation insurance policy shall be liable for a civil penalty of up to $1,000.00 per offense. (36 OS

§§924.5)

It is a crime to falsify the information on this form.

Edition 070106

Affidavit Of Exempt Status Under Worker Compensation - Uco Page 2

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