Form 309-6701 - Contractor Registration Application/renewal Form/form 60-0126 - Report To Determine Liability Page 2
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87. Nature of business in Iowa ***(Must show both business activities & detailed description)***
Primary Business Activity:
In space below - Please give detail of the primary Iowa business activity
8. Physical location where work is performed in Iowa: City
County
Banking/Financial Institution Information
Checking
Savings
Institution Name:
City:
Zip Code:
Address:
State:
Phone:
I certify that the information in this application is true and correct to the best of my knowledge. I further certify that the company
listed on this form is in compliance with the workers' compensation laws of the State of Iowa as indicated below.
(Check one box and enclose required workers' compensation form)
Insured: Enclosed is a Certificate of Workers' Compensation Insurance listing the Iowa Division of Labor as a certificate holder
Self-insured: Enclosed is a copy of Certificate of Relief issued by the Iowa Insurance Division
No employees / Workers' Compensation form not required
Name of Person Completing Form (Print or Type):
Company Name:
E-mail Address of Company or Individual (Print or Type):
Signature of Person Completing Form:
Date Signed:
Notice Regarding Social Security Numbers
Iowa Code sections 252J.8, 261.126 and 272D.8, require records of contractor registrations issued to sole proprietors to be
maintained by social security numbers. If you are a sole proprietor and you withhold your social security number, this application
will be denied. Social security numbers may be shared with Child Support Recovery Unit, Department of Human Services, The
Student College Aid Commission and The Department of Revenue, for use in the collection of debts. If you are behind in
payments, this or future applications may be denied. If you already have a registration it may be suspended or revoked. Your
social security number may also be shared with other governmental agencies.
**Fee Exemption Instructions
Fee Exemption forms may be obtained from our web site at The fee exemption
only applies to a self-employed contractor. Other legal entities do not qualify. If all of the following are true, you may qualify for
an exemption of the $50 yearly registration fee:
l I am a self-employed contractor.
l I do not pay more than $2,000 per year for all employees combined (not including myself.)
l I never perform construction work with or for other contractors working in the "same phase of construction" at the job site.
(The "same phase of construction" is defined as the same type of work, such as masonry, stonework, electrical work or
concrete work, etc.)
l If applicable, I have enclosed a list of all current employees and a list of all employees who have worked for me for
l the past 12 months and the amount paid to each employee.
The exemption form must be signed by the Contractor & Notarized and must accompany the registration application.
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