IN THE WORKERS' COMPENSATION COURT OF THE STATE OF MONTANA
) ) Petitioner ) ) WCC No. vs. ) ) PETITION DISPUTING ICCU ) REVOCATION OF INDEPENDENT ) CONTRACTOR EXEMPTION ) INDEPENDENT CONTRACTOR CENTRAL UNIT) Respondent. )
1. On ____________________________, I received an independent contractor exemption certificate. A copy of the certificate is attached. 2. My exemption was revoked on _______________________________. A copy of the revocation notice is attached. 3. The mediation process before the Department of Labor and Industry has been completed. ยง 39-71-415, MCA. 4. I am appealing the revocation and request the Workers' Compensation Court to determine that I am an independent contractor entitled to an independent contractor exemption. DATED this day of , 2008.
Petitioner's Signature Please print or type: Name: Street Address: City, State, Zip: Telephone #: Attach copies of application for Independent Contractor Exemption and revocation
notice