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IMPORTANT: PLEASE READ BEFORE COMPLETING APPLICATION

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1 WCB-266 ( eff. 08/01/2013) IMPORTANT: PLEASE READ BEFORE COMPLETING APPLICATION NOTICE TO APPLICANT: predetermination of independent contractor status is based upon the information provided in this APPLICATION . Participation in the submission of a fraudulent or intentionally misleading form can result in fines of up to $1,000 for an individual and up to $10,000 for a corporation, partnership or other legal entity. The predetermination WILL NOT apply if you do not perform work consistent with the information provided in this APPLICATION .

predetermination before working as an independent contractor. • If you file this application, it may be: Granted or denied (you will receive a letter to this effect); or, instead of denying it, the Board may return your application and request additional information.

  Request, Predetermination

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