Form 68-0192 - Questionnaire For Determining Status Of Worker Page 4
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5Questionnaire for Determining Status of Worker
(Continued)
68-0192 (04-12)
Relationship of the Firm and Worker
Are benefits available to the workers? (e.g., vacation pay, sick pay, healthcare, etc.) ____Yes ____No
If “Yes”, list: _______________________________________________________________________________________
Can the firm or worker end this relationship at anytime without incurring liability or penalty? ____Yes ____No
If “No”, explain: _____________________________________________________________________________________
Can the firm discharge the worker at any time? ____Yes ____No
If “Yes”, explain: ____________________________________________________________________________________
Did the worker perform similar services for others during the same time period? ____Yes ____No
If “Yes”, is the worker required to get the firm's approval? ____Yes ____No
Are there any agreements preventing competition between the firm and the worker? ____Yes ____No
If “Yes”, attach any available documentation.
Under whose name is the advertising placed? ____Firm ____Worker
How does the firm present the worker to its customers? _____________________________________________________________
If the worker assembles or processes a product at home, who provides the materials and instructions?
____Firm ____Worker ____Other
What does the worker do with the finished product? _______________________________________________________________
Does the worker still perform services for the firm? ____Yes ____No
If “No”, how did the relationship end? ____________________________________________________________________
For Service Providers or Salespersons
Does the worker sell insurance or real estate? ____Yes ____No
If “No”, list the product(s) or service(s) being sold ___________________________________________________________
Does the worker solicit new customers? ____Yes ____No
Does the firm provide the worker with customer leads? ____Yes ____No
Is the worker required to follow up on leads furnished by the firm? ____Yes ____No
Are there any reporting requirements pertaining to the leads? ____Yes ____No
Are any terms and conditions of sale required by the firm? ____Yes ____No
If “Yes”, describe: ___________________________________________________________________________________
Are orders submitted and subject to the firm's approval? ____Yes ____No
Does the firm determine the worker's territory? ____Yes ____No
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