IN THE WORKERS= COMPENSATION COURT OF THE STATE OF MONTANA ) ) ) ) ) ) ) ) ) ) ) ) Petitioner vs. INDEPENDENT CONTRACTOR CENTRAL UNIT Respondent. WCC No. PETITION DISPUTING INDEPENDENT CONTRACTOR DETERMINATION 1. I am appealing the Determination of the Independent Contractor Central Unit dated ________________________________, 20__. A copy of the Determination is attached. 2. The mediation process before the Department of Labor and Industry has been completed. ' 39-71-415, MCA. 3. Explain in detail the nature of the dispute. (Use additional pages if necessary.) _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 4. The following is a list of individuals who I may call as witnesses in this matter: Name and Address General Subject Matter of Testimony American LegalNet, Inc. www.FormsWorkFlow.com 5. The following is a list of written documents relating to this case which I may introduce as evidence: 6. I request that the Workers= Compensation Court reverse the Determination of the Independent Contractor Central Unit. DATED this day of , 20__. Signature of Petitioner Please print or type: Name: Mailing Address: City, State, Zip: Telephone #: E-Mail Address: _____________________________________ Attach a copy of the Independent Contractor Central Unit Determination. American LegalNet, Inc. www.FormsWorkFlow.com