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Form SS-8 (Rev. 5-2014)
Page
Part V
For Service Providers or Salespersons. Complete this part if the worker provided a service directly to
customers or is a salesperson.
1
What are the worker’s responsibilities in soliciting new customers?
2
Who provides the worker with leads to prospective customers?
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Describe any reporting requirements pertaining to the leads.
4
What terms and conditions of sale, if any, are required by the firm?
5
Are orders submitted to and subject to approval by the firm? .
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Yes
No
6
Who determines the worker’s territory?
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Did the worker pay for the privilege of serving customers on the route or in the territory? .
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Yes
No
If “Yes,” whom did the worker pay?
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If “Yes,” how much did the worker pay?
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8
Where does the worker sell the product (for example, in a home, retail establishment)?
List the product and/or services distributed by the worker (for example, meat, vegetables, fruit, bakery products, beverages, or laundry or dry
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cleaning services). If more than one type of product and/or service is distributed, specify the principal one.
10
Does the worker sell life insurance full time? .
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Yes
No
11
Does the worker sell other types of insurance for the firm? .
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Yes
No
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If “Yes,” enter the percentage of the worker’s total working time spent in selling other types of insurance .
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12
If the worker solicits orders from wholesalers, retailers, contractors, or operators of hotels, restaurants, or other similar
establishments, enter the percentage of the worker’s time spent in the solicitation .
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%
13
Is the merchandise purchased by the customers for resale or use in their business operations? .
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Yes
No
Describe the merchandise and state whether it is equipment installed on the customers’ premises.
Under penalties of perjury, I declare that I have examined this request, including accompanying documents, and to the best of my knowledge and belief, the
facts presented are true, correct, and complete.
Sign
Title
Date
Here
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Type or print name below signature.
SS-8
Form
(Rev. 5-2014)