Petition Disputing Iccu Determination
ADVERTISEMENT
1IN THE WORKERS’ COMPENSATION COURT OF THE STATE OF MONTANA
)
)
Petitioner
)
)
WCC No.
vs.
)
)
PETITION DISPUTING ICCU
)
DETERMINATION
)
(NON-WORKERS’ COMPENSATION)
)
Respondent.
)
1.
On _______________________, I applied for an independent contractor exemption.
A copy of my application is attached.
2.
My request for the independent contractor exemption certificate was denied on
____________________. A copy of the denial is attached.
3.
The mediation process before the Department of Labor and Industry has been
completed. § 39-71-415, MCA.
4.
I am appealing the denial and request the Workers’ Compensation Court to
determine that I am an independent contractor entitled to an independent contractor
exemption.
DATED this
day of
, 20__.
Signature of Petitioner
Please print or type:
Name:
Street Address:
City, State, Zip:
Telephone #:
Attach copies of Independent Contractor Exemption and denial letter
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal