MWCPF Independent Contractor Worksheet at a glance
What it is: The Michigan Workers' Compensation Placement Facility Independent Contractor Worksheet.
Where and when to file: 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.
What to bring and attach to MWCPF Independent Contractor Worksheet
For 1, mark how you operate: Sole Proprietor, Partnership, Corporation or Limited Liability Company. If indicating Partnership, Corporation or Limited Liability Company, a Certificate of Workers' Compensation Insurance or a properly filed Form BWC-337 must be submitted.
A filled-in MWCPF Independent Contractor Worksheet example: a sole proprietor fills out the worksheet
How to fill out MWCPF Independent Contractor Worksheet, box by box
Policyholder Name, Subcontractor Name and Doing Business As (DBA)
Enter the Policyholder Name the form is being filled out for, the Subcontractor Name and the Doing Business As (DBA). If DBA is filed, attach a copy.
The type of work I perform
For 2, fill in The type of work I perform can be described as. For 3, mark Yes if you hire employees or casual laborers to complete work for the named policyholder, or No. If Yes, enter the Number hired and attach a Certificate of Workers' Compensation Insurance. If No, Form 1040 SCHEDULE C (Profit or Loss from Business) may be provided as verification.
General contractors or clients
To validate your standing as an independent contractor, you state that you do not exclusively depend upon the payments of the named policyholder and have worked for general contractors or clients during the past twelve months: list the NAME, CITY and TELEPHONE on lines 1, 2 and 3.
Signed, Date, Phone Number and Email Address
Sign on Signed, as the Independent Contractor, and enter the Date, the Phone Number and the Email Address (Required).
You certify this represents a true and complete statement of your status as an Independent Contractor. You understand a company representative may verify this statement at any time. If requested, you agree to provide documentation to verify your status as a sole proprietor.
You acknowledge that as a sole proprietor, you are by law not covered by or subject to the Workers' Disability Compensation Act.
More rules for MWCPF Independent Contractor Worksheet
Mark Yes if you hire subcontractors to complete work for the named policyholder, or No. If yes, additional information may be required.
Mark Yes if you have General Liability coverage, or No. If yes, a Certificate of General Liability Insurance is required.
Completing this form does not automatically remove the 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.
Sources
[1] Michigan Workers' Compensation Placement Facility Circular Letter #222, Independent Contractor Worksheet, October 3, 2008 (the Official source link on this page).
