IN THE WORKERS' COMPENSATION COURT OF THE STATE OF MONTANA ) ) ) Petitioner ) ) vs. ) ) ) ) ) ) INDEPENDENT CONTRACTOR CENTRAL UNIT) Respondent. )
WCC No.
PETITION DISPUTING DENIAL OF INDEPENDENT CONTRACTOR STATUS (NON-WORKERS' COMPENSATION)
1. I am appealing the Determination of the Independent Contractor Central Unit dated ________________________________, 2008, which denied my application for certification as an independent contractor. A copy of the Determination is attached. 2. The mediation process before the Department of Labor and Industry has been completed. ยง 39-71-415, MCA. 3. I am appealing the denial and request the Workers' Compensation Court to reverse the Determination of the Independent Contractor Central Unit. DATED this day of , 2008.
Signature of Petitioner Please print or type: Name: Street Address: City, State, Zip: Telephone #: _____________________________________
Attach copy of the Independent Contractor Central Unit Determination