Michigan Workers Independent Contractor Worksheet PDF Details

In the complex and ever-evolving world of work, the lines between being an independent contractor and an employee can sometimes blur, sparking crucial discussions and necessitating crystal-clear distinctions. The Michigan Workers' Compensation Placement Facility (MWCPF) has taken a step towards clarifying this with the introduction of the Independent Contractor Worksheet, a vital document for sole proprietors seeking to establish their status as independent contractors within Michigan's regulatory framework. Dated October 3, 2008, and set to impact policies on and after July 1, 2009, this initiative signals a departure from the previous practice of solely relying on a Certificate of Insurance (COI) for determining independent contractor status in the residual market. The form prompts individuals to disclose their business structure, the nature of their work, employment of labor, subcontracting practices, and insurance coverage, along with evidence of work for other clients to substantiate their independence. This comprehensive approach not only solidifies the standing of sole proprietors in workers' compensation considerations but also streamlines the process for all parties involved, ensuring a more transparent and equitable treatment across Michigan's labor landscape.

QuestionAnswer
Form NameMichigan Workers Independent Contractor Worksheet
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesindependent compensation michigan, workers mi caom, michigan workers compensation placement facility independent contractor worksheet, michigan independent contractor form

Form Preview Example

MICHIGAN WORKERS’ COMPENSATION PLACEMENT FACILITY

P.O. Box 3337 Livonia, MI 48151-3337

(734) 462-9600 Fax (734) 462-9721

Internet WEB Site: www.caom.com E-Mail: caom@caom.com

October 3, 2008

CIRCULAR LETTER #222

MICHIGAN WORKERS’ COMPENSATION PLACEMENT FACILITY (MWCPF)

INDEPENDENT CONTRACTOR WORKSHEET

It has been an accepted practice in the residual market to consider a sole proprietor without employees as an independent contractor, if a Certificate of Insurance (COI) for the individual is presented. Effective July, 1, 2009, this practice will cease in the residual market (on new and renewal policies as of that date). In order for a sole proprietor without employees to be considered for independent contractor status, the MWCPF Independent Contractor Worksheet must be completely filled out and supplied to the entity undergoing a workers compensation audit.

Attached is a copy of the worksheet. As indicated on the worksheet, additional information may be requested to determine independent contractor status.

Sincerely,

Gary L. Thompson

MICHIGAN WORKERS’ COMPENSATION PLACEMENT FACILITY

INDEPENDENT CONTRACTOR WORKSHEET

TO BE COMPLETED BY THE INDEPENDENT CONTRACTOR

Policyholder Name form is being filled out for:

Subcontractor Name:

Doing Business As (DBA):

 

 

If DBA is filed, attach a copy.

 

1. I operate as a :

Sole Proprietor

Partnership

Corporation

Limited Liability Company

Note: If indicating

Partnership, Corporation or Limited Liability Company, a Certificate of Workers’

Compensation Insurance or a properly filed Form BWC-337 must be submitted.

 

2.The type of work I perform can be described as:

3.I hire employees or casual laborers to complete work for the named policyholder:

Yes

 

Number hired (Attach Certificate of Workers’ Compensation Insurance)

No

Form 1040 SCHEDULE C (Profit or Loss from Business) may be provided as verification.

4. I hire subcontractors to complete work for the named policyholder: Yes No If yes, additional information may be required.

5. I have General Liability coverage: Yes No

If yes, a Certificate of General Liability Insurance is required.

6.To validate my standing as an independent contractor, I state that I do not exclusively depend upon the payments of the named policyholder and have worked for the following general contractors or clients during the past twelve months.

NAME

CITY

TELEPHONE

1.

2.

3.

I acknowledge that as a sole proprietor, I am by law not covered by or subject to the Workers’ Disability Compensation Act.

I certify the above represents a true and complete statement of my status as an Independent Contractor. I understand a company representative may verify this statement at any time. If requested, I agree to provide documentation to verify my status as a sole proprietor.

Signed:

 

 

 

 

Date:

 

 

 

(Independent Contractor)

Phone Number:

 

Email Address :

 

(Required)

This form is utilized as a test of the above individual’s independent status. By completing this form, it does not automatically remove the above individual’s exposure from the audit of the policy period in question. Additional information may be required. If independent status is proven, the exposure will not be charged.

ICW08

How to Edit Michigan Workers Independent Contractor Worksheet Online for Free

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Step 1: Select the button "Get Form Here" and click it.

Step 2: The moment you access our independent compensation michigan editing page, you'll see all of the options you may take about your form within the top menu.

Fill out the independent compensation michigan PDF and type in the material for every segment:

example of gaps in michigan workers facility

Remember to provide your particulars in the segment TO BE COMPLETED BY THE INDEPENDENT, Policyholder Name form is being, Subcontractor Name, Doing Business As DBA, If DBA is filed attach a copy, I operate as a cid Sole, Note Compensation Insurance or a, If indicating Partnership, The type of work I perform can be, cid Yes cid No, I hire employees or casual, Number hired Attach Certificate of, Form SCHEDULE C Profit or Loss, and I hire subcontractors to complete.

TO BE COMPLETED BY THE INDEPENDENT, Policyholder Name form is being, Subcontractor Name, Doing Business As DBA, If DBA is filed attach a copy, I operate as a cid Sole, Note Compensation Insurance or a, If indicating Partnership, The type of work I perform can be, cid Yes cid No, I hire employees or casual, Number hired Attach Certificate of, Form SCHEDULE C Profit or Loss, and I hire subcontractors to complete in michigan workers facility

Type in all particulars you need inside the section NAME, CITY, TELEPHONE, I acknowledge that as a sole, I certify the above represents a, Signed, Date, Independent Contractor, Phone Number, Email Address, Required, This form is utilized as a test of, and ICW.

michigan workers facility NAME, CITY, TELEPHONE, I acknowledge that as a sole, I certify the above represents a, Signed, Date, Independent Contractor, Phone Number, Email Address, Required, This form is utilized as a test of, and ICW blanks to fill

Step 3: Hit the Done button to save your form. So now it is ready for transfer to your electronic device.

Step 4: Make a duplicate of each file. It will certainly save you time and assist you to avoid problems as time goes on. By the way, your information isn't going to be shared or checked by us.

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