South Dakota > Workers Compensation
Independent Contractor Verification Application - South Dakota
| Independent Contractor Verification Application Form. This is a South Dakota form and can be used in Workers Compensation . |
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South Dakota Department of LaborKneip Building, Third Floor700 Governors DrivePierre, South Dakota 57501-2277INDEPENDENT CONTRACTOR VERIFICATION APPLICATION_______________________________________________________________Use this form to verify your status as an independent contractor as permitted bySDCL 62-1-11, and ARSD chapter 47:03:07. Answer the following questionscompletely; a question may be answered by "N/A" (not applicable) or "seeanswer #" if appropriate. If more space is needed, use additional pages (identifyyour response with the question number). Any supporting documents should beattached to this application. If you have any questions about the informationrequested, please call (605) 773-3681.________________________________________________________________1. Name, address, and phone number of applicant.2. Name(s) of all contractees (person (s) or firm (s) with whom the applicant contracts to provide services.)<<<<<<<<<********>>>>>>>>>>>>> 23. Does the applicant own a vehicle licensed and registered as a truck, road tractor, or truck tractor? Please identify the licensing and registering governmental agencies, and any license or registration numbers.4. Are the services provided under a written agreement between the owner- operator and the contractee? If so, please submit a copy.5. Is the applicant responsible for the maintenance of the vehicle?6. For which of the following expenses is the applicant responsible while on the road? ( Please circle. ) Fuel Repairs Supplies Vehicle insurance Personal7. a. How is the applicant paid by the contractee (salary, commission, hourly wage, by mileage or load, etc.)? b. Does the contractee report the applicants income to the Internal Revenue Service? If so, how is that income reported? (1099, W-2, other). c. Does the contractee allow the applicant a drawing account or advances<<<<<<<<<********>>>>>>>>>>>>> 3 against pay? If so, how does the applicant repay such draws or advances? d. Does the contractee carry workers compensation insurance on the applicant? e. Does the contractee pay unemployment insurance taxes on behalf of applicant?8. Does the applicant have helpers? If so, a. Does the contractee have to hire or approve them? b. Does the contractee have to pay them, or reimburse the applicant for their pay?8. a. Does the contractee train the applicant? If so, please explain: c. Does the applicant direct the details of the way the work is done? (performing the service, conforming with regulatory requirements, conforming with operating procedures of a commercial carrier, meeting shippers specifications.) If not, please specify the direction given by the contractee.<<<<<<<<<********>>>>>>>>>>>>> 4Please send a completed copy of this application to:South Dakota Department of LaborKneip Building, Third Floor700 Governors DrivePierre, SD 57501-2277The applicant, by its authorized representative: Authorizes the department to audit or investigate the accuracy of any statement made in this application and related documents; Agrees to assist the department in conducting the audit or investigation; and Agrees to allow the department access to its place of business and to information and record requested by the department.The applicant understands and agrees that if a material fact in this application orrelated documents has been misrepresented or if the applicant no longer meetsthe requirements of the law and administrative rules, the department may deny ormay suspend or revoke the independent contractor certification of the applicantunder ARSD 47:03:07:04.________________________________________________________________APPLICANT NAME APPLICANT SIGNATURE DATE SIGNED
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