Independent Contractor Form

Independent Contractor Form

Complete the form below and choose “Submit.”

Alternatively, you may download, print and mail a completed copy of the Independent Contractor Form (PDF) to:

CompOne Administrators
PO Box 2530
Okemos, MI 48805

If you need a paper copy of your submission, please print the PDF and fill out with your information. If you choose to submit via the online form, your information is secure and sent directly to the CompOne team, but you will not receive a paper copy of your submission.

TO BE COMPLETED BY THE INDEPENDENT CONTRACTOR

Subcontractor Name(Required)
I operate as:
*NOTE: If indicating Partnership, Corporation or Limited Liability Company, a Certificate of Workers' Compensation insurance or a properly filed BWC 337 form MUST be submitted in PDF format.
Max. file size: 100 MB.
I hire employees or casual laborers to complete work for the named policyholder:(Required)
IF YES: You MUST attach a certificate of Workers' Compensation Insurance in PDF format. IF NO: Form 1040 schedule C may be provided as verification in PDF format.
Max. file size: 100 MB.
I hire subcontractors or casual laborers to complete work for the named policyholder:(Required)
I have General Liability and/or Professional Liability Coverage:(Required)
To validate my standing as an independent contractor, I state that I do not exclusively depend upon the payments of the named policyholder and have worked for the following general contractors or clients during the past twelve months:
I acknowledge that as a sole proprietor, I am by law not covered by or subject to the Workers’ Disability Compensation Act. I certify the above represent a true and complete statement of my status as an Independent Contractor. I understand a company representative may verify that statement at any time. If requested, I agree to provide documentation to verify my status as a sole proprietor.
Name: Independent Contractor(Required)
MM slash DD slash YYYY
This form is utilized as a test of the above individual's independent status. By completing this form, it does not automatically remove the above individual's exposure from the audit of the policy period in question. Additional information may be required. If independent status is proven, the exposure will not be charged.