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IMPORTANT: PLEASE READ BEFORE COMPLETING APPLICATION

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 .

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

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