APPLICATION FOR PREDETERMINATION OF INDEPENDENT CONTRACTOR STATUS TO ESTABLISH CONCLUSIVE PRESUMPTION STATE OF MAINE Workers' Compensation Board 27 STATE HOUSE STATION AUGUSTA, ME 04333-0027 TEL: (207) 287-7071 FAX: (207) 287-5413 TDD: (877) 832-5525 LANDOWNER NAME ADDRESS NUMBER AND STREET CITY STATE ZIP TELEPHONE NUMBER LANDOWNER'S AGENT (IF APPLICABLE): NAME ADDRESS NUMBER AND STREET CITY STATE ZIP TELEPHONE NUMBER I, ______________________________________________(landowner or landowner's agent), hereby request a predetermination pursuant to 39-A M.R.S.A. �� 105 and 401 that the relationship between the above-named landowner and the following individual or company is that of landowner/independent contractor within the definitions contained in 39-A M.R.S.A. �� 102(13) and 401(4). WOOD HARVESTER NAME ADDRESS NUMBER AND STREET CITY STATE ZIP TELEPHONE NUMBER THIS DOCUMENT MAY BE PRODUCED IN ALTERNATIVE FORMATS SUCH AS BRAILLE, LARGE PRINT AND AUDIO TAPE. WCB-260(eff. 1/1/13) American LegalNet, Inc. www.FormsWorkFlow.com (1) Answer each of the following questions accurately and completely. 1. (a) Have you enclosed a copy of the wood harvesting contract? YES _____ (b) NO _____ If applicable, have you enclosed a copy of the contract, between the landowner and the landowner's agent, that establishes an agency relationship? YES _____ NO _____ 2. Does the wood harvester employ assistants to help in executing the contract? YES _____ NO _____ If no, does the wood harvester have the authority to hire such assistants? YES _____ 3. NO _____ Does the wood harvesting contract expressly state that the independent contractor will not hire any employees to assist in the wood harvesting without first providing a certificate of insurance to the landowner showing that the independent contractor has obtained the required coverage for independent contractor's employees? YES _____ NO _____ 4. (a) Which party supplies the tools and equipment that is needed to perform the work? LANDOWNER ____WOOD HARVESTER ____ OTHER (PLEASE SPECIFY)__________ (b) What tools are supplied? 5. Who has control over the day-to-day operation of the work? 6. What is the duration of the agreement to perform work? (If there is no specific term or duration to the contract, describe how the contract can be terminated.) American LegalNet, Inc. www.FormsWorkFlow.com (2) 7. Will the wood harvester be performing the same type of work for other landowners while completing this contract? YES _____ If yes, please describe: NO _____ 8. What are the terms of payment? (That is, is the wood harvester paid a specific sum of money, by the hour, by the amount of wood cut, or by some other method?) 9. Does the landowner make withholdings from the payments made to the wood harvester for social security, income taxes, unemployment or any type of insurance? YES _____ If yes, please explain: NO _____ 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 predetermination of independent contractor status shall be nullified. I further understand that this predetermination of independent contractor status is based upon the information provided in this application and that any changes in these circumstances may nullify the predetermination of independent contractor status. I agree to notify the Workers' Compensation Board of any subsequent changes. SIGNATURE OF LANDOWNER/AGENT DATE SIGNATURE OF WOOD HARVESTER DATE American LegalNet, Inc. www.FormsWorkFlow.com