LB-0977 (REV 10/15) RDA 10183 Bureau of Workers325 Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 615-532-1319 FAX: 615-253-6256 EMPLOYEE MISCLASSIFICATION TIP FORM Misclassification occurs when workers that should be treated as employees are incorrectly treated, by the employer, as independent contractors. This is unfair to the workers and unfair to other employers. Why do you think there is misclassification? Business Name: Name of Owner(s): Name of a contact person at the business: Email: Street Address: City: State: Zip: County: Business Phone: Home Phone: Cell Phone: Fax: Other locations or worksites: Describe what kind of work the Employees of this Business perform: How did this come to your attention? (please be specific) When are the workers typically on the worksite? How are they paid? Cash Payroll Check Personal Check Other Are taxes deducted? No Yes Unsure Are pay stubs provided? No Yes Are deductions taken out of for workers325 compensation premiums? Yes No Unsure When are the wages paid? Daily Weekly When job is completed Other How many hours per week do the employees normally work? If you are willing to be contacted about this request, please provide your: Email Phone # Printed Name of Requesting Party: Signature Date American LegalNet, Inc. www.FormsWorkFlow.com