Form Wce-1 - Application For Worker'S Compensation Clearance Certificate

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WCE-1

APPLICATION FOR WORKER’S COMPENSATION

CLEARANCE CERTIFICATE

State Form 45899 (R6 / 12-09)

Indiana Department of Revenue / Worker’s Compensation Board of Indiana

INSTRUCTIONS:

Please type or print.

Payment must be made using a money order or certified check.

Mail this completed application and payment to the Indiana Department of Revenue, PO Box 2305, Indianapolis, IN 46204-2305.

Name of independent contractor (last, first)

Name of business

Specified trade

Address (number and street, city, state, and ZIP code)

Telephone number

(

)

E-mail address

Social Security Number *

Affidavit of exemption number (STATE USE ONLY)

Are you an Indiana resident?

If no, please enter your state of residence

Yes

Under the provisions of IC 22-3-2-14.5 and/or IC 22-3-7-34.5, I, the undersigned, am hereby requesting issuance to me of an Independent Contractor

Affidavit of Exemption:

I am an independent contractor working in the construction trades, as defined by IC 22-3-6-1 (b) (7) and / or IC 22-3-7-9 (b) (5).

I am an independent contractor working in ___________________________________ under the name ___________________________________.

I am the sole proprietor as defined by IC 22-3-6-1 (b) (4) and IC 22-3-7-9 (b) (2) and am thereby exempted from worker's compensation coverage.

Type of business

Name of sole proprietorship

Social Security Number

I am a partner in a partnership as defined by IC 22-3-6-1 (b) (5) and IC 22-3-7-9 (b) (3) and am thereby exempted from worker's compensation coverage.

Name of partnership

Federal Identification Number

I am an officer of a corporation who is the sole officer of the corporation and I elect not to be an employee under this chapter as defined by

IC 22-3-6-1 (b) (1) and IC 22-3-7-9 (b) (9).

Name of corporation

Social Security Number or Federal Identification Number

do not have other employees.

do not have Worker’s Compensation insurance through a private insurance carrier.

Signature of applicant

Date signed (month, day, year)

This affidavit certifies that the above named person is an independent contractor as defined by the indicated provisions of law, that the above named

person has worker's compensation or is a qualified self-insurer as to any and all employees in their hire, and that the above named person desires to be

exempt from worker's compensation coverage and foregoes the right of recovery under the Worker's Compensation Act from anyone for whom this

person works as an independent contractor. This affidavit is binding and holds harmless any person and their worker's compensation insurance carrier

contracting with the above named person (as an independent contractor) and their worker's compensation insurance carrier. This affidavit is not valid

without the stamp of the Worker's Compensation Board. This affidavit is valid for one year from the date of issue. You must re-apply each year to

maintain exempt status. This information may be shared with the Internal Revenue Service and/or other states.

FOR STATE USE ONLY

A $20.00 non-refundable filing fee is required.

Date issued (month, day, year)

$5.00 Department of Revenue filing fee paid

$15.00 Worker’s Compensation Board filing fee paid