Independent Contractor Form - University Of Alaska Fairbanks Page 4
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4Independent Contractor Status Determination Form
Contractor and Departmental Certification:
I certify, to the best of my knowledge, the information provided is true, correct and complete. I authorize the
University of Alaska to use this information for determination of independent contractor status and to release
such information as may be required to the Internal Revenue Service and auditors of the University and its
programs.
Contractor:
Signature______________________________
Date_______________________
Printed Name___________________________
Requesting University Department:
Signature______________________________
Date_______________________
Printed Name___________________________
Contractors Not Meeting Insurance Requirements:
If a reasonable request for an insurance waiver has been made and the exposure to loss is substantially limited
by the nature of the work performed, or by other coverage, the general liability insurance requirement may be
reviewed by the University and waived by its Risk Manager by signing below.
Commercial General Liability Insurance: Waived:_______
Not Waived:_______
State law requires the University to ensure that all contractors maintain workers’ compensation insurance. This
insurance requirement can only be waived if one of the following are attached:
1
A certificate of waiver approved by the Alaska Department of Labor (or state of residence of the
contractor’s employees), or
2
Other sufficient written proof and/or affidavit that establishes to the satisfaction of the University of
Alaska that the contractor does not have, and will not have during the contract term, any employees
subject to the workers’ compensation insurance requirements for the state of employee residency.
Workers’ Compensation Insurance:
Waived:_______
Not Waived:_______
Comments: ________________________________________________________________________________
_________________________________________________________________________________________
Signature______________________________________
Date_______________________
Risk Manager
Printed Name__________________________________
Determination of Status:
To be completed by Vice Chancellor for Administrative Services, or designee, if work is to be performed for a
campus department, or by UA Controller, or designee, if work is to be performed for a UA SW department.
Approved:
_______
Disapproved
_______
(if not approved, indicate primary reasons for non-approval): ____________________________________
____________________________________________________________________________________
Signature____________________________________
Date________________________
VCAS, UA Controller, or Designee
Printed Name________________________________
Title__________________________________
Rev. 10-17-2011
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