1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 Telephone 1-800-777-5033 Fax 701-328-3750 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com INDEPENDENT CONTRACTOR’S AFFIDAVIT OF NON-EMPLOYMENT OUT OF STATE EMPLOYER EMPLOYER SERVICES / PHS DIVISION SFN 53069 (09/2006) Name SSN Business Federal ID# Business Name North Dakota Secretary of State (SOS) System Identification Number Type of Ownership: Individual Limited Liability Partnership (LLP) Partnership Limited Liability Corporation (LLC) Corporation Other: Please provide street address and post office box for both business and home Business Address Business Phone City State Home Address Home Phone City State Name of North Dakota Project Primary North Dakota Business Contact Zip Code Zip Code Start Date End Date Check all that apply My organization does not employ any workers as defined under North Dakota workers’ compensation law. See reverse for NDCC § 65-01-02 (16) As an Independent Contractor and owner of a business, I choose to waive optional coverage on myself. I understand that means I am not entitled to any workers’ compensation benefits if I am injured at work. (All officers, partners and owners must complete and sign this section.) Please list all officer(s), partner(s), and owner(s) of the business Social Security % Full Name (including middle initial) Title Date of Birth Number Owned Signature Signature Signature I have elected optional coverage. My WSI Account Number is : American LegalNet, Inc. www.FormsWorkflow.com INDEPENDENT CONTRACTOR’S AFFIDAVIT OF NON-EMPLOYMENT OUT OF STATE EMPLOYER CONT’D PAGE 2 OF 2 Acknowledgement It is understood that if my organization does employ any worker, I will notify WSI before any actual work has been performed by any employee. I understand it is unlawful for me to employ workers without securing workers’ compensation insurance coverage. I understand that failure to comply with the requirements of the workers’ compensation act may subject me to criminal, injunctive, and monetary penalties. I certify that the information contained in this affidavit is true and correct to the best of my knowledge. I further certify if any of the representations I have made to WSI change, I am obligated to contact WSI with accurate and current information. Dated this day of , . (Signature) Acknowledged before me this , In (County) (State) (Title) day of , 20 , . Notary Public NDCC § 65-01-02 (16) 16. "Employee" means a person who performs hazardous employment for another for remuneration unless the person is an independent contractor under the "common law" test. a. The term includes: (1) All elective and appointed officials of this state and its political subdivisions, including municipal corporations and including the members of the legislative assembly, all elective officials of the several counties of this state, and all elective peace officers of any city. (2) Aliens. (3) County general assistance workers, except those who are engaged in repaying to counties moneys that the counties have been compelled by statute to expend for county general assistance. (4) Minors, whether lawfully or unlawfully employed; a minor is deemed sui juris for the purposes of this title, and no other person has any claim for relief or right to claim workforce safety and insurance benefits for any injury to a minor worker, but in the event of the award of a lump sum of benefits to a minor employee, the lump sum may be paid only to the legally appointed guardian of the minor. b. The term does not include: (1) Any person whose employment is both casual and not in the course of the trade, business, profession, or occupation of that person's employer. (2) Any person who is engaged in an illegal enterprise or occupation. (3) The spouse of an employer or a child under the age of twenty-two of an employer. For purposes of this paragraph and section 65-07-01, "child" means any legitimate child, stepchild, adopted child, foster child, or acknowledged illegitimate child. (4) Any real estate broker or real estate salesperson, provided the person meets the following three requirements: (a) The salesperson or broker must be a licensed real estate agent under section 43-23-05. (b) Substantially all of the salesperson's or broker's remuneration for the services performed as a real estate agent must be directly related to sales or other efforts rather than to the number of hours worked. (c) A written agreement must exist between the salesperson or broker and the person or firm for whom the salesperson or broker works, which agreement must provide that the salesperson or broker will not be treated as an employee but rather as an independent contractor. (5) The members of the board of directors of a business corporation who are not employed in any capacity by the corporation other than as members of the board of directors. (6) Any individual delivering newspapers or shopping news, if substantially all of the individual's remuneration is directly related to sales or other efforts rather than to the number of hours worked and a written agreement exists between the individual and the publisher of the newspaper or shopping news which states that the individual is an independent contractor. (7) An employer. c. Persons employed by a subcontractor, or by an independent contractor operating under an agreement with the general contractor, for the purpose of this chapter are deemed to be employees of the general contractor who is liable and responsible for the payments of premium for the coverage of these employees until the subcontractor or independent contractor has secured the necessary coverage and paid the premium for the coverage. This subdivision does not impose any liability upon a general contractor other than liability to the organization for the payment of premiums which are not paid by a subcontractor or independent contractor. American LegalNet, Inc. www.FormsWorkflow.com