Sole Proprietor Form printable pdf download

Sole Proprietor Form

SOLE PROPRIETOR FORM

For Sole Proprietor’s with No Employees

For workers’ compensation purposes we are required to maintain verification regarding workers’

compensation coverage for all of our independent contractors.

You must provide the following information if you:

a) Are a sole proprietor with no employees, and

b) Do not carry workers’ compensation insurance.

1) Name of Sole Proprietor:_________________________________________________

2) Social Security Number or Federal Tax Identification Number:__________________

3) I am doing business as:__________________________________________________

Please attach one of the following:



A copy of the assumed name certificate you filed with the county; or



Your business card; or



A copy of your advertisement (Yellow Pages, Newspaper, etc); or



List one other business or private homeowner that you have worked for during the period of

July 1, through current date, including the name and address:_________

___________________________________________________________________________

Please complete the following statement:

I, ______________________________________, a Sole Proprietor with no employees will

provide__________________________ services to ___________

_______________________________ on a periodic basis. I do understand that I am not entitled to

workers’ compensation benefits under Michigan’s Law, therefore, I am personally responsible for

any injuries/illnesses I may sustain while performing my services to said entity.

Dated at:___________, on this_______________ day of _________, _________.

Signed:___________________________________________________________

Sole Proprietor

STATE OF MICHIGAN, COUNTY OF_____________________________________________

On this_________________ day of________________, _______________ before me personally

appeared ____________________, who being duly sworn did state that s/he is not entitled to

workers’ compensation benefits as indicated under Michigan’s Law, and will not hold responsible

the above named entity s/he may provide services to for any injury(ies) illness(es) s/he may sustain

while performing such indicated services.

Seal/Stamp

__________________________________________

Notary Public, _______________________County

My commission expires______________________

Sole Proprietor Form