Form 45899 - Independent Contractor Affidavit Of Exemption - State Of Indiana

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INDEPENDENT CONTRACTOR AFFIDAVIT

Worker's Compensation Board

OF EXEMPTION

402 West Washington Street, Room W196

* According to IC 22-3-2-14.5, it is mandatory that your

State Form 45899 (R3 / 1-96)

Indianapolis, Indiana 46204-2753

Social Security number be given; this form cannot be

Approved by State Board of Accounts 1993

processed without it.

Name of independent contractor (type or print)

Trade name of independent contractor

Specified trade

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

Federal identification number or Social Security number *

Affidavit of exemption number (STATE USE ONLY)

Telephone number (including area code)

(

)

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 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. Sole proprietorship name:

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. Partnership name:

I have employees.

My independent contractor business is incorporated and I am an officer of that corporation.

Yes

Under the penalties provided for by IC 22-3-4-13, I attest that the above information is true and correct and that I meet the requirements established for issuance of an Independent

Contractor Affidavit of Exemption.

Signature of applicant

Date signed

$5.00 Filing Fee Required Upon Validation

This affidavit certifies that the above named person is an independent contractor as defined by the indicated provisons 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.

STATE USE ONLY

Signature of official

Date issued

Form 79 filing

$5.00 fee paid

SP: ______ P: ______

Receipt number _____________________

MAKE CHECKS PAYABLE TO: WORKER'S COMPENSATION BOARD

DISTRIBUTION: White - Agency; Canary - Revenue; Pink - Contractor