Petition Disputing Iccu Revocation Of Independent Contractor Exemption printable pdf download

Petition Disputing Iccu Revocation Of Independent Contractor Exemption

IN THE WORKERS’ COMPENSATION COURT OF THE STATE OF MONTANA

)

Petitioner

)

WCC No.

vs.

)

PETITION DISPUTING ICCU

)

REVOCATION OF INDEPENDENT

)

CONTRACTOR EXEMPTION

)

_____________________________________ )

Respondent.

)

On ____________________________, I received an independent contractor

exemption certificate. A copy of the certificate is attached.

My exemption was revoked on _______________________________. A copy of

the revocation notice is attached.

The mediation process before the Department of Labor and Industry has been

completed. § 39-71-415, MCA.

I am appealing the revocation 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__.

Petitioner’s Signature

Please print or type:

Name:

Street Address:

City, State, Zip:

Telephone #:

Attach copies of application for Independent Contractor Exemption and revocation

notice

Petition Disputing Iccu Revocation Of Independent Contractor Exemption