I WCE-1 State Form WORKER’S COMPENSATION CLEARANCE CERTIFICATE APPLICATION Name of Independent Contractor (type or print) Last, First Address (number, and street, city, state, ZIP code) (including area code) (State Use Only) Are you an Indiana resident? Yes No If no, please enter your state of residence: Under the provisions of IC 22-3-2-14.5 and/or IC 22-3-7-34.5, I, the undersigned, am hereby requesting issuance to me of an compensation coverage. Sole proprietorship name:______________________________ SSN: ____________________ compensation coverage. Partnership name:_____________________________ FID: ____________________ Yes Yes No Yes Signature of Applicant No No If no, state of residence is: ____________________ If no, state of residence is: ____________________ If no, state of residence is: ____________________ Date signed You must re-apply each year to maintain exempt status. This information may be shared with the Internal Revenue Service and/or other states. State Use Only $20 Non-Refundable Filing Fee Required Date issued Please mail to: American LegalNet, Inc. www.FormsWorkFlow.com This form is only to be used by independent contractors in the building and/or construction trades. The Indiana Department of Revenue may share this information with the Internal Revenue Service (IRS) and /or other states. contractor or an employee. Listed below are some of the characteristics of each. An independent contractor generally: directs his own work and performs the work in the manner he chooses, without direction from the general contractor; sets his own hours; may hire assistants; provides his own tools and materials; is paid by the job rather than by the hour; An employee generally: is under the control of his employer; receives pay on an hourly basis; must perform the work in the manner indicated by the employer; receives training, tools and equipment provided by the employer; is not free to offer his services to many persons or and to offer his services to the general public. Are you new to the state of Indiana or the United States? (nonrefundable) to the If you do not meet the criteria for establishing your status as an independent contractor, you will be contacted with instructions American LegalNet, Inc. www.FormsWorkFlow.com