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INDEPENDENT CONTRACTOR 1I3SURANCE STATUS <br />k. DaMLARATION-MUST BE CONPLWITD <br />"he undersigned performs contractural work for the state of Colorado <br />Mame Of pe=son.company or corporation policy number <br />(herein referred to as the Aprime contractor=) as an Aindependent contractor_ and claims to be <br />-xemapt from workers compensation insurance coverage by virtue of meeting the following <br />Drovisions of CRS 8-48-101(2-5), as amended: <br />(1) F own <br />Located at <br />(2) <br />(3) <br />(4) <br />I manage and control such business, company or service. <br />I have ultimate responsibility for all decisions affecting such business, company or <br />service. <br />I am subject to realize any profit or loss from such business, company or service as <br />evidenced by my being required to file a Tax Schedule C, or Schedules A and L (Forma <br />1065) of the Partnership Tax Return with the Federal Internal Revenue Service annually_ <br />3ecause I am exempt, <br />:he <br />understand that if I am injured while performing contractural work for <br />.he Prime contractor, I will not be covered for such injury under the prime contractor s <br />:assurance policy unless I have checked item B-3 below. I further undersand that I am still <br />required to provide worker's compensation insurance for all of my employees. <br />living read and understood the above provisions, I certify under the penalty of perjury that I <br />feet all of the above requirements and am thereby exempt form the Workmen's Compensation Act. <br />name o i� f owner <br />t c =racto /or '.5iminess tit? e <br />Y gnature a tTactor -16 `�ate .2 '��••.s�I�% <br />socia se= ty'r`e or f'e tax <br />i I - nmICAT8 ntsupascs ELEc__.1O T pvBpRRmK3 <br />(1) Being exempt from the Colorado Workmen's Compensation Act, I have elected not <br />to be covered under a workers, compensation policy. <br />(2) Although I am exempt for the Act as evidenced above, I have elected to be <br />covered under my own policy number with <br />which expires on <br />name of insurance company <br />(3) The prime contractor hasdate <br />agreed to cover me on its police beginning on _ <br />I understand that the cost of my coverage will be deducted from payments to me <br />by��the Prime contractor as provided by law. <br />�l �TOT� a%t,��s��trflri ,e•� <br />name of < tractor or <br />title <br />10-23 <br />a''"ig�tLre of p -2 3 -/Z <br />=�-'a'Pe'--dew tractor <br />tate <br />y: <br />signature of prize contractor <br />date <br />CIA Copy (White) Prime Contractor Copy (pink) <br />Accountant Copy (yellow) <br />