Pinnacol Contractor Status Form – Fill Out and Use This PDF

Declaration of Independent Contractor Status Form

According to the Colorado Workers’ Compensation Act, a person is an independent contractor, not an employee, if

both of the following statements are true.

1.He/she is free from control and direction in the performance of the service (unless control is exercised under the requirement of any state or federal statute or regulation).

2.He/she is customarily engaged in an independent trade, occupation, profession, or business related to the services performed.

The Colorado Workers’ Compensation Act also outlines nine criteria (listed on page 2) to help determine whether or

not the above statements are true. For an individual to be considered an independent contractor, he/she must meet only those criteria that are appropriate to the situation. He/she does not need to meet all of the nine criteria.

This Declaration of Independent Contractor Status Form documents the business relationship as defined in the Colorado Workers’ Compensation Act. It is the responsibility of our policyholders and their independent contractor(s)

to correctly and truthfully complete this form. Pinnacol Assurance will accept this form only when it is initialed where applicable, signed, and notarized by both parties. If you do not understand this form, do not sign it.

If you have any questions, please contact a member of Pinnacol’s customer service team at 303.361.4000 or 800.873.7242.

Please make copies of this form as needed. You should complete this form only once for each independent contractor for the lifetime of your Pinnacol policy or until the business relationship changes.

This form is not valid unless a signed and notarized copy of the form is returned to Pinnacol Assurance. Keep the original for your records and send a copy to Pinnacol. You can do this the following ways:

∙Email: customer_service@pinnacol.com

∙Mail: Pinnacol Assurance P.O. Box 469011 Denver, CO 80246-9011

∙Fax: 303.361.5000

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Declaration of Independent Contractor Status Form

We certify UNDER PENALTY OF PERJURY that (insert contractor’s name and trade name below):

Name: __________________________________________ Trade name: _________________________________

Performing (type of work):_______________________________________________________________________

Federal Employer Identification #: ________________________________________________________________

Address: ____________________________________________________________________________________

Phone:______________________________________________________________________________________

Is an independent contractor (IC) and is not an employee of the following policyholder (PH):

Policyholder’s name: ___________________________________________________________________________

Address: ____________________________________________________________________________________

Policy #:_________________________________________Phone:______________________________________

We also certify, by OUR initials WHERE APPLICABLE, that the above business for which the above individual performs services meet the following criteria:

Do not forget to complete page 3 of this form, which contains the Certification by the Independent Contractor. This certification must be signed and notarized.

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Certification by Independent Contractor

The independent contractor understands that he/she:

∙Will not be entitled to any workers’ compensation benefits in the event of injury.

∙Is obligated to pay all federal and state income tax on all money earned while performing services for the business.

∙Is required to provide workers’ compensation insurance for all workers that he/she hires.

Signature: ___________________________________________ Title: ___________________________________

Last four digits of Social Security #: XXX-XX-_____________(please do not provide us with your complete Social Security #)

Acceptance of the Independent Contractor named on this form does not change any party’s responsibility under the Workers’ Compensation Act. If individuals or organizations hired or contracted by the Independent Contractor are not covered by other workers’ compensation insurance, the policyholder specified on this form will be charged

premium for coverage of those individuals or organizations.

Notary Public

Subscribed and sworn before me by: ________________________________

This ________ day of ____________________________ , _____________

Commission expires:_____________________________________________

Signature: ____________________________________________________

________________________________________________________________________________

Certification By Pinnacol Policyholder

I certify that I am authorized by the business listed above to state that all of the information on this form is true and accurate. I understand that if the above person does not qualify for independent contractor status, the proper premium can be assessed.

Signature: ___________________________________________ Title: ___________________________________

Policy # or Federal Employer Identification #: _______________________________________________________

Notary Public

State of Colorado )

)§§

County of )____________________________________________

Subscribed and sworn before me by: ________________________________

This ________ day of ____________________________ , _____________

Commission expires:_____________________________________________

Signature: ____________________________________________________

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