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APPLICATION for Independent Contractor Exemption ...

DLI-ERD-WCR003 Revised: Mar 2020 APPLICATION for Independent Contractor Exemption Certificate VALID FOR TWO (2) YEARS IC# OFFICE USE $125 FEE (NON-REFUNDABLE) INSTRUCTIONS: Visit us online at or call (406) 444-7734 for BLOCK FOR OFFICE USE Complete this APPLICATION form if you have an independently established trade, occupation, profession, or business, are free from the control and direction of your hiring agent, and are not personally covered by a Montana workers compensation insurance policy. Read and complete the associated waiver form if you understand and agree to its provisions.

my work performance under an ICEC, this waiver is effective against any of my beneficiaries as designated under the Act. initial I understand and agree that if my ICEC is granted, I will be conclusively presumed in court to have waived all benefits under the Act for work performed under the certificate. initial

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SAMPLE MEMORANDUM OF AGREEMENT - ERD …

erd.dli.mt.gov

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Overview of Workers Compensation Benefits21 - Montana

erd.dli.mt.gov

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