STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION AUGUSTA, ME 04333-0027 TEL: 207-287-3751 FAX: 207-287-5413 TDD: (877) 832-5525 APPLICATION FOR A CERTIFICATE OF INDEPENDENT STATUS I, , hereby request, pursuant to 39-A M.R.S.A. Secs. 105 and 401, a Certificate of Independent Status. WOOD HARVESTER: NAME ADDRESS NUMBER AND STREET CITY STATE ZIP TELEPHONE NUMBER Please answer each of the following questions accurately and completely. 1. (a) Do you work alone? YES_____ (b) NO_____ (Please check If the answer to Question 1(a) is NO, do you work with appropriate box(es).) Parent_____ Spouse_____ Sibling_____ Partner_____ Child_____ Niece_____ Nephew_____ Other (please describe)____________________ 2. Please list the tools and equipment that you own and use to harvest wood. a separate sheet if necessary.) (Attach THIS DOCUMENT MAY BE PRODUCED IN ALTERNATIVE FORMATS SUCH AS BRAILLE, LARGE PRINT AND AUDIO TAPE. WCB-262(eff. 1/1/13) American LegalNet, Inc. www.FormsWorkFlow.com -2� 3. Who is in charge of your day-to-day operations? 4. Do you usually work for more than one landowner during the course of a year? YES_____ NO_____ 5. Please describe who you have done work for during the last twelve (12) months. (Attach a separate sheet if necessary.) Landowner: Start Date_______________ End Date_____________ 6. Please describe who you will be doing work for during the next twelve (12) months. (Attach a separate sheet if necessary.) Landowner: Start Date______________ End Date_____________ 7. Please check the boxes that indicate how you are paid for harvesting wood. By the Hour_____ By the Job (in a lump sum)_____ By the Cord_____ By Board Feet_____ Other (please describe)_________________________________________ Please read carefully and sign below. I hereby certify that the foregoing information is truthful and accurate. I understand that should any information contained in this application be found to be intentionally misleading or fraudulent, the Certificate of Independent Status shall be nullified. I further understand that the Certificate of Independent Status is based upon the information provided in this application and that any changes in these circumstances may nullify the Certificate of Independent Status. I agree to notify the Workers' Compensation Board of any subsequent changes. _______________________________ DATE __________________________________ SIGNATURE OF WOOD HARVESTER American LegalNet, Inc. www.FormsWorkFlow.com