INDEPENDENT CONTRACTOR INFORMATION PACKET · 2017-12-13 · INDEPENDENT CONTRACTOR PACKET...

INDEPENDENT CONTRACTOR INFORMATION PACKET Revised 12/12/2017

FOR QUESTIONS, PAPERWORK OR OTHER INFORMATION:

Email: [email protected]

Submit Daily Paperwork: [email protected]

Telephone: 970-482-4888 ext. 342

Fax: 970-482-4904

Physical Address: 7301 SW Frontage Road, Suite 3 Fort Collins, CO 80528

mailto:[email protected]


INDEPENDENT CONTRACTOR PACKET

Independent Contractor Packet v5.0 Last Updated: 12/12/17

ABOUT US

Transpro Burgener is a leading provider of bulk material hauling services, specializing in infrastructure, energy and industrial transport throughout the Rocky Mountain region. Headquartered in Fort Collins, CO, and operating out of terminals in Laramie, WY, Fort Collins, CO, Denver, CO and Pueblo, CO, the Company transports a diverse line of materials including cement, frac sand and other aggregate materials that support construction and infrastructure markets as well as the DJ/Niobrara, Williston and Powder River energy basins.

WHY WORK WITH US?

• A FAMILY COMPANY

o Transpro Burgener traces its roots back to 1946, and has been family owned for three generations. o Our third generation President is still actively engaged in the business and makes all strategic decisions. o We minimize red tape. You can still have a personal conversation with Management – just pick up the

phone!

• A BUSINESS PARTNER o We are looking for long term relationships, not vendors. o We have more business than we can handle so we can help you keep your trucks busy. o We can assist you with your maintenance, fuel and equipment needs. o We are willing to do what it takes to keep you rolling and making money!

• MINIMIZE YOUR OVERHEAD

o We have quality, long-lived customer relationships that rely on us on a regular basis. You can leverage off our sales efforts and relationships and avoid creating your own sales organization.

o We have a professional dispatch department that operates 24/7. There is no need for you to take calls at all hours of the day or night – we’ll do it for you.

o We process invoices, bill customers, work on collections issues and pay you for your hauls regardless of when the customer pays.

• CASH FLOW

o We offer standard 45 day payment terms, with the option for you to be paid in 7 days. That increases your cash flow and makes it easier for you to keep rolling.

o We allow you to utilize our trailers so you don’t have to worry about taking the risk of purchasing your own.

o We can net maintenance, repairs and fuel out of your settlements to improve your cash flow.



WHAT WE NEED FROM YOU

It is easy to work with us! If fact, you probably already have most of the information you need.

• A CUSTOMER-FOCUSED ATTITUDE At Transpro Burgener, the Customer is #1. We expect all our drivers and business partners to do

everything necessary to satisfy the customer, every time.

• EQUIPMENT You need your own truck, preferably with a blower if you haul commodities in pneumatic trailers. Our

customers have various equipment needs, so the more capabilities your truck has, the more work you will get.

If you don’t own your own trailers (pneumatic, belly dump, side dump, end dump), we can make arrangements for you to use one of ours for a fee.

• AUTHORITY TO OPERATE

You have to have your own DOT number. Since many of our loads cross state lines, we’d prefer if you had your own MC number. This is not

required, but again, if you have it you will get more loads. Have IRP registration (apportioned plates) so you can operate in multiple states.

• INSURANCE *

General Liability Insurance Requirement $1,000,000 Automotive Liability Insurance Requirement $1,000,000 Cargo Coverage $ 10,000 Physical Damage (non-owned trailers) $ 60,000

* Note: Transpro Burgener Trucking must be listed as “Additional Insured” Do you have employees?

No – We need a Declaration of Independent Contractor Status Form (see packet) Yes – We need proof of Worker’s Compensation Insurance

• A TAX ID NUMBER

We need a completed W-9 form showing your Tax Identification Number (TIN) or Social Security Number (SSN) in order to report your settlements.



WHAT YOU GET FROM US

As a large trucking company with many customers and well-established financial resources, we can offer you many benefits:

• STEADY WORK We have a varied customer base including clients in the aggregate, construction, energy, and industrial

material markets. This is beneficial because when one market is less active, we typically have another that is very active – which evens out the available work.

• PAYMENT OPTIONS 45 Day Terms – normal payment terms are 45 days, regardless of when or if the customer pays us. Quick Pay Terms – we offer a Quick Pay option so you can get paid in 7 days. There is a 4.5% fee

associated with the Quick Pay option. Payment by ACH – we can pay you by bank transfer so you get the funds in your account quicker. This

service is free! Payment by Check – we can pay you by paper check if you wish.

• EQUIPMENT MAINTENANCE/REPAIR

Since we are working together, it is our goal to keep you running and efficient. At times you may elect to have us perform maintenance or repairs on your truck to quickly get you up and running again.

In special cases, we may choose to work together if you want to add special purpose equipment (blowers, wet kits) to your truck. Since we are a large company, we are often able to offer you specialty equipment below your cost.

• FUEL If you have a consistent work history with us and agree to weekly settlements, we can work together on

a program for you to purchase fuel from us for your truck(s). Given our volume of fuel purchases, we can sometimes offer you a discount versus market pricing.



LET’S GET STARTED!

We are excited to have you on-board and look forward to working with you. Now that you’ve made the decision to partner with us, here’s what a normal week (our weeks run from Sunday to Saturday) might look like:

• DAY 1 (Sunday): Your completed Independent Contractor Packet is entered into our system and your contact information is passed along to our dispatchers. We will also email you numbers for our dispatch team so that you can contact them to inquire about loads as well.

• DAY 2 (Monday): You place a call to our Dispatch (or our Dispatch calls you) and offers you a load/loads. You complete your loads and email your paperwork (bills of laiding, scale tickets, Transpro Burgener cover sheets) to [email protected].

• DAYS 3-7 (Tuesday-Saturday): You continue to work with Dispatch to accept and complete loads for customers on a timely basis. You continue to submit your daily paperwork by dropping it by our office or scanning and emailing it to us).

• DAY 9 (Monday): You stop by the Transpro Burgener Fort Collins office and drop off all your remaining paperwork for last week by 9:00am. You can also email this paperwork to [email protected] (in this case, you will need to follow up by mailing originals to our Fort Collins office). This is CRITICAL to getting paid on a timely basis!

• DAY 11 (Wednesday): You receive a settlement statement via email (and check or ACH payment if you elected Quick Pay) detailing out each load you hauled and how much you were paid for it. The settlement will show deductions for repairs, trailer usage fee, factoring fee (if applicable), fuel purchases, etc. If you do not elect Quick Pay, you will still receive your settlement statement, but you will receive your check in 45 days.

If this summary of the benefits of working with Transpro Burgener has you interested, fill out the attached agreement and forms and return them to our office or email them to [email protected] as soon as possible. We’ll have you on the road with us before you know it!





Independent Contractor Packet v5.0 Last Updated: 12/12/17 Initial ___________

INDEPENDENT CONTRACTOR AGREEMENT

Between

CARRIER Transpro, Inc. (“CARRIER”) d/b/a Transpro Burgener Trucking 7301 SW Frontage Road Suite 3 Fort Collins, CO 80528

And

INDEPENDENT CONTRACTOR Name: ________________________ (“CONTRACTOR”) DBA Name: ________________________ Address: ________________________ ________________________ Telephone: ________________________ Email Address: ________________________ Date: ________________________ (“AGREEMENT DATE”)

Section 1: Recitals

Transpro, Inc. is a Colorado Corporation (hereinafter referred to as “Carrier”) engaged as a for-hire interstate motor

carrier of property, registered with the Federal Motor Carrier Safety Administration (“FMCSA”) of the United States

Department of Transportation (“DOT”).

Independent Contractor (hereinafter referred to as "Contractor") is engaged in the trucking business and is fully familiar

with the trucking services to be provided and the conditions under which the work is to be performed. Contractor has

title to the vehicle(s) described in Appendix A to this Agreement (hereinafter referred to as "Contractor Equipment"), or

has the right to the exclusive use of this Contractor Equipment, and has lawful possession of this Contractor Equipment.

Contractor has all state, federal, county, or city certificates, permits, registrations, authorizations and licenses that are

required or necessary for the conduct of business and the performance of transportation services under the terms of

this Agreement. Contractor will continue to have such certificates, permits, registrations, authorizations and licenses in

full force and effect at all times while providing services under the terms of this Agreement.



Carrier desires to enter into an agreement to engage Contractor, as an independent contractor, for the purpose of

transporting dry bulk commodities, construction materials and/or general freight in interstate commerce, as may be

provided by Carrier. Contractor desires to contract with Carrier to transport said commodities.

Therefore, in consideration of mutual promises and agreements set in Independent Contractor Agreement

(“Agreement"), Carrier and Contractor agree as follows:

Section 2: Scope of Operations

During the term of this Agreement, Contractor may contact Carrier from time to time to determine whether Carrier has

any shipments that require transportation. In the event Carrier has shipments that Contractor agrees to transport,

Carrier shall notify Contractor of material to be transported and of the time and location to load and time and location

to deliver same, all within a reasonable time prior to the required delivery time. Thereafter, Contractor will, without

delay, cause said material to be transported to the place designated by Carrier or by Carrier’s representative.

Carrier will use reasonable efforts to provide Contractor goods, materials or loads for transportation by Contractor;

however, this Agreement shall not be construed as an agreement by Carrier to furnish any specific amount of goods,

materials, or loads for transportation by Contractor in any particular time or place. Carrier makes no guarantee of

minimum payment for use of the Contractor Equipment. Likewise, Contractor shall have the right, at its discretion, to

decline to transport any shipment tendered to it by Carrier, or to refuse to perform specific requests by Carrier to

provide transportation. Contractor shall have the right to perform transportation services for other Carriers (subject to

the provisions of Section 3), and this Agreement may be terminated at such times.

Contractor shall perform transportation and related services as may be necessary to serve Carrier’s Customers to

protect customers’ cargo against loss and damage. All services hereunder will be provided by the Contractor Equipment

under Contractor's FMCSA operating authority. Contractor or another employed person with an appropriate

commercial driver’s license may provide the transportation services required hereunder.

Contractor shall maintain all insurance coverage required by law and Section 9 of this Agreement in full force and effect

for the full term of this Agreement. In the event of a lapse in Contractor's insurance coverage, said lapse will constitute a

material breach of this Agreement.



Contractor warrants that the Contractor Equipment is in good state of repair, meets all safety requirements of all

applicable Federal and State laws and is properly licensed and permitted for operation, and that all licensing conditions

and safety requirements that may be applicable for continued legal operation of the Contractor Equipment shall be

followed. Contractor shall not obligate Carrier for payment of any expense associated with licensing of the Contractor

Equipment. Contractor shall immediately notify Carrier and cease to provide all services under this Agreement in the

event Contractor's operating authority is suspended or revoked by any state DMV, DOT and/or FMSCA during the time

this Agreement is effective. Suspension of Contractor’s operating authority will constitute a material breach of this

Agreement.

Contractor shall be responsible for all costs and expenses incident to its performance of services, including all operating

and maintenance costs for the Contractor Equipment provided by Contractor, including fuel and oil, special permits, all

detention and accessorial services, gross revenue taxes, road taxes, tolls and ferries, equipment use fees or taxes, base

plates, and any other tax, fine, or fee imposed or assessed against the Contractor Equipment, cargo, or Carrier by any

local, state or federal authority as a result of the acts or omissions of Contractor or the employees, agents or servants of

Contractor.

Carrier shall act as a dispatching agent for Contractor.

Contractor shall be responsible for cargo hauled for Carrier's customer and shall obtain and deliver to Carrier completed

and duly receipted documents, including bills of lading, waybills, freight bills, manifests or other papers identifying the

property carried on Contractor Equipment (hereinafter known as a "freight bill") covering such shipments transported.

Contractor agrees that all freight bills shall be those of the Carrier, or as authorized by the Carrier, and shall indicate that

the property transported is under the responsibility of the Carrier. Prior to payment for services rendered, it shall be the

Contractor's responsibility to obtain freight bills, to procure the necessary signatures, and to deliver, scan or mail all

freight bills to Carrier's office, or other location designated by Carrier, no later than 24 hours after completion of the

workday covered by the freight bill.

Subject only to requirements imposed by law, Contractor shall direct, in all respects, the operation of its Contractor

Equipment used, and shall exercise full discretion and judgment as an Independent Contractor in determining the means

and methods of performance of service under the terms of this Agreement.



Section 3: Confidentiality/Non-Competition

Carrier is engaged in the provision of transportation and related services and has accumulated trade secrets, pricing

data, technology and other proprietary information pertaining thereto (“Confidential Information”). Confidential

Information includes, but is not limited to, (1) any information, ideas, plans or strategies, in any form, relating to

Carrier’s business, marketing, sales, structure, financial affairs, research, designs, products, equipment, data and

information systems, vendors, Contractor partners, and employees and (2) any information relating to the discussions,

negotiations, agreements, dealings, projects, pricing or business between Carrier and Contractor. Contractor shall treat

as confidential and shall not, directly or indirectly, cause or permit to be used or disclosed or to make available to any

other person, any Confidential Information received, learned, observed, known by or made available to Contractor.

Contractor acknowledges that freight that is made available to Contractor under this Agreement is the result of Carrier’s

significant investment of time, effort and resources in developing customer relationships. Contractor and its employees

or subcontractors shall not, directly or indirectly, transport or solicit for transport any freight from consignees or

customers serviced by the Carrier, unless the Contractor has a preexisting relationship with such customer. In

consideration of Carrier’s significant investment and other consideration received by Contractor pursuant to this

Agreement, Contractor agrees that, for a period of 24 months following the termination of this agreement pursuant to

the provisions of Section 12, that neither Contractor nor its employees, agents or subcontractors shall solicit

transportation services for any shipper or customer of the Carrier, unless the Contractor had a preexisting relationship

with such customer. If it is discovered that the Contractor has breached any provision of Section 12, the Contractor

agrees to pay the Carrier 15% of the gross revenues derived from such activities.

Section 4: Safety

Contractor shall comply fully with all laws, orders, citations, rules, regulations, standards and statutes with respect to

safety. Contractor shall conduct inspections to determine that safe working conditions exist at all times and that the

Contractor Equipment complies with safety regulations at all times. Contractor accepts sole responsibility for the safety

of its employees, if any, and agrees to perform all services hereunder in a safe, responsible and lawful manner.

Contractor shall ensure that all vehicles used by Contractor to provide the services covered by this Agreement are in safe

operating condition and that they are operated in compliance with all applicable provisions of local, state and federal

law, including, but not limited to, the FMSCA Regulations, applicable state codes, and safety regulations promulgated by

the Occupational Safety and Health Administration and the Mine Safety and Health Administration.



Contractor shall immediately notify Carrier of any accident or incident involving property damage or bodily injury to

persons that occurs while performing service for Carrier or when pulling Carrier's trailer equipment (the “Trailer

Equipment"). Such notification shall include a description of damage or injury; digital pictures of physical damage to

Trailer Equipment and/or third party equipment; an estimated cost of repair with documentation supporting the cost

estimate, date, time and location of occurrence; name, address, and telephone number of witnesses to either the

occurrence or the existence of any damage claimed; and the name, address and telephone number of the person using

the Contractor Equipment and/or the Trailer Equipment at the time of the accident/incident. Failure to immediately

notify Carrier of an accident/incident shall constitute a material breach of this Agreement, in accordance with Section

12. Contractor shall follow all safety rules and regulations and safety gear requirements required at Carrier’s customer

jobsites to which Contractor is dispatched.

Contractor shall be required to enroll in a Drug and Alcohol Testing Consortium pursuant to 49 CFR Section 382.107 and

to comply with all applicable rules, laws, regulations and reporting requirements. Contractor shall furnish to Carrier a

Certificate of Compliance stating that Contractor is enrolled in such Drug and Alcohol Testing Consortium.

Section 5: Timely Performance

Timely performance is the essence of this Agreement. Insofar as practical, Carrier shall provide Contractor with

reasonable scheduling information. Contractor agrees to begin the work promptly as scheduled and as requested by

Carrier, to perform diligently, in a safe manner, in good faith and in full cooperation with Carrier and with Carrier's

customers, and to complete the work as requested by Carrier. Failure to maintain the timely performance standard

herein set forth shall constitute a material breach of this Agreement.

Section 6: Trailer Usage

Contractor is not required to purchase or utilize any products, Trailer Equipment or services from Carrier as a condition

of entering into this Agreement. However, Contractor may utilize Trailer Equipment, for a fee, from Carrier in the event

it is available. If Contractor chooses to utilize products, Trailer Equipment or services from Carrier, Contractor authorizes

Carrier to make corresponding deductions from Contractor’s settlement compensation as specified in the Trailer Usage

Form contained in this Agreement. The term "Trailer Equipment" as used herein shall include the trailers and all

attached components-if provided-including tie-down gear, tarps, hoses, tires and brakes; and shall include trailers

owned by and/or otherwise under control of Carrier. Carrier will make Carrier's Trailer Equipment available for use by

Contractor at Carrier's sole discretion.



Carrier will designate the Trailer Equipment to be utilized to Contractor. Contractor shall use only the Trailer Equipment

specified by Carrier, and shall not switch trailers without express written permission from Carrier. Said Trailer

Equipment shall be used only by Contractor and/or Contractor's qualified employees or agents, and then only to provide

service in accordance with the terms of this Agreement. Carrier's Trailer Equipment shall not be used by Contractor to

provide transportation service to other parties. Trailer Equipment shall be promptly returned to Carrier in the event

Contractor is not engaged to haul loads for the Carrier for a period of one month. Trailer Equipment that is not returned

in such a time frame will be subject to monthly rental charges until returned to the Carrier.

Contractor shall make no physical change or alteration (exclusive of repairs described below) to Carrier's Trailer

Equipment without prior written consent of Carrier. None of the tires or other components of Carrier's Trailer

Equipment are to be used or altered in any way other than as expressly provided for in this Agreement. Any alteration

requested by Contractor, which is agreeable to Carrier, will be made by Carrier at Contractor's sole expense. If expenses

are incurred by Carrier in returning the Trailer Equipment to its original condition, such expenses will be borne by

Contractor and shall be deducted from payment due Contractor.

Carrier makes no warranties, expressed or implied, as to the condition of the Trailer Equipment or the adequacy of any

repair. Contractor will make Carrier's Trailer Equipment available for inspection and repair at any location determined

by Carrier at a time arranged by Carrier in order to conform to Carrier's maintenance program.

Prior to any use, Contractor shall inspect all Trailer Equipment utilized or provided by Carrier and promptly report, in

writing, any defects or problems to Carrier. All mechanical defects on said Trailer Equipment not reported in writing to

Carrier prior to Contractor's use of said Trailer Equipment shall be the responsibility of Contractor. Contractor shall be

responsible for inspecting, in accordance with applicable law, any Trailer Equipment owned by or under control and

authority of Carrier and used by Contractor with Carrier's permission while performing services for Carrier. Contractor

shall inspect Carrier's Trailer Equipment on a daily basis; record such inspections on a Driver’s Vehicle Inspection Report.

Contractor will notify Carrier in writing when any defects are noted. All repairs of Carrier’s Trailer Equipment will be

made at Carrier's maintenance facility unless otherwise approved by Carrier. Contractor shall verify and inspect all

repairs of Carrier’s Trailer Equipment and approve in writing the Driver’s Vehicle Inspection Report indicating such.

Maintenance of proper brake adjustment for the Trailer Equipment will be Contractor's responsibility. Weekly

lubrication of all grease fittings and correction of minor repair items will also be Contractor’s responsibility.



Repairs of damage to Carrier’s Trailer Equipment attributable to normal wear-and-tear will be made at Carrier’s

expense. Contractor agrees to compensate Carrier for damage to Carrier's Trailer Equipment (other than that

attributable to normal wear-and-tear), including damage caused by negligence, accident, theft or vandalism.

Section 7: Relationship of Parties

It is the express intent of all the parties hereto that Contractor is an independent contractor, and not an employee,

agent, joint venture, or partner of Carrier for any purpose whatsoever. This Agreement is intended by the parties to

create the relationship of Carrier and independent contractor, and not an employer-employee relationship. Neither the

Contractor nor its employees shall be considered employees of Carrier at any time under any circumstances, or for any

purpose. Neither party is the agent of the other, and neither party shall have the right to bind the other by contract or

otherwise, except as herein specifically provided in the Agreement. Carrier shall have no right to, and shall not, control

the manner or prescribe the method of accomplishing those services which shall be contracted to and performed by

Contractor pursuant to this Agreement.

The provisions of this Agreement that reserve ultimate authority to Carrier have been entered into to ensure compliance

with federal and state laws, rules, and interpretations thereof. None of the provisions of this Agreement shall be

interpreted or construed as creating or establishing an employer-employee relationship between Carrier and Contractor

or between Carrier and any driver, agent, servant, or other employee of Contractor.

Section 8: Compliance with Law

Contractor is responsible for complying with all applicable laws, rules, regulations, ordinances and other requirements

imposed by federal, state, county or municipal government authority in the conduct of its business. Contractor is

responsible for ensuring that its employees are in compliance with all applicable laws, rules, regulations, ordinances, and

other requirements imposed by federal, state, county or municipal government authority in the conduct of its business.

Contractor shall defend, indemnify and hold Carrier harmless from any violation of any applicable laws, rules,

regulations, ordinances and other requirements imposed by federal, state, county or municipal government authority. If

Carrier incurs any loss or expense due to a violation, such loss or expense shall be borne by Contractor and shall be

deducted from payment due to Contractor.

Carrier shall have no obligation or responsibility to Contractor or Contractor’s employees, agents, or servants for any

fine, cost or penalty, monetary or otherwise, arising out of Contractor or Contractor's employees' violation of any law,



rule, ordinance, or regulation of any and all governmental authority in and through whose jurisdiction Contractor or its

employees may be operating while providing service for Carrier under this Agreement.

Section 9: Contractor's Employees

Contractor shall furnish at its discretion, selection and expense any labor required incident to the operation of the

Contractor Equipment and the Trailer Equipment and the pickup, packing, loading, unloading, assembling,

disassembling, delivering, and documentation of shipments in performance of services to be provided under this

Agreement.

Contractor shall be solely responsible for the direction and control of its employees, agents and servants, if any,

performing services for Contractor under this Agreement. Contractor shall be responsible for the selection, hiring,

terminating, training, supervision, work assignment, and direction of its employees, agents and servants. Contractor

shall be responsible for the wages, hours, and working conditions of its employees, and for addressing its employees'

grievances. Contractor shall determine the method, means, and manner of the performance of the work of its

employees, agents, and servants, if any, and performance of services pursuant to this Agreement.

Carrier shall neither have, nor exercise, disciplinary authority or control over Contractor’s employees. Carrier shall have

no authority to supervise or direct Contractor’s employees in the performance of work for Contractor, and shall have no

authority or right to select, approve, hire, terminate, or discipline any of Contractor's employees.

Contractor assumes full and sole responsibility for the payment of all wages, benefits and expenses of its employees,

agents, or servants (including without limitation, the payment of prevailing wages), if any, and for all state and federal

income tax withholding, unemployment insurance, and social security taxes as to all persons employed by Contractor.

Contractor shall be responsible for meeting and fulfilling the requirements of all regulations now or hereafter prescribed

by governmental authorities with respect hereto. In no event shall Carrier be responsible for the wages, benefits or

expenses due Contractor’s employees, agents or servants. Carrier is not authorized to withhold state or federal income

taxes, Social Security taxes, unemployment insurance taxes, or any other local, state or federal tax and/or levy on behalf

of Contractor or Contractor's employees. Contractor shall defend, indemnify, save and hold harmless Carrier from any

and all liability, losses, costs or expenses Carrier may incur by Contractor's failure to comply with the terms of this

Agreement.



Contractor agrees to make certain and warrants and represents that all persons retained to drive vehicles hereunder will

hold the appropriate commercial driver's license required by state or federal authority. Contractor agrees that all

persons retained by Contractor to drive vehicles shall fully satisfy and comply with any and all applicable federal and

state regulations governing the operation of commercial vehicles on the public highways. Contractor shall not allow any

person identified as a “negligent operator" by any state or federal law to operate a vehicle hereunder. Upon written

request, Contractor shall provide Carrier the drive file maintained for each driver allowed to drive a vehicle hereunder

and/or copies of all driver daily logs for those days when the driver performed any service hereunder.

Contractor assumes full responsibility for maintaining adequate worker’s compensation insurance coverage for itself and

all employees, agents or servants whom Contractor retains to perform services related to this Agreement. Contractor

shall provide Carrier with appropriate written evidence of said coverage by which Carrier agrees, upon reasonable

request by Carrier, to provide Carrier with a list of all driver employees covered by Contractor's worker's compensation

insurance policy. Contractor agrees to defend, indemnify and hold Carrier harmless from any and all liability, regardless

of the cause thereof, including attorney's fees, imposed or claimed, arising out of any injury, disability or death of any

person who performs services under this Agreement.

In the event that any judgment is enforced against Carrier for any costs or expenses resulting from any employment or

other relationship of employees, agents, or contractors of Contractor, Contractor agrees to defend, indemnify and hold

Carrier harmless from and against any liability, expense or costs arising out of such judgment.

Section 10: Liability and Insurance

During the term of this Agreement, Contractor shall obtain and maintain insurance with coverage and limits no less than

required by law and such higher limits and coverage as specified herein to fully protect Contractor and Carrier. In the

event this Agreement is terminated, such insurance shall provide coverage for claims that occurred during the term of

the Agreement, but were not reported until after this Agreement was terminated, for a period of two (2) years after

termination. Carrier is not responsible for premiums for the required insurance. These requirements shall automatically

increase to the extent required by law. Contractor shall procure and maintain at its own expense for the term of this

Agreement, the following insurance coverage:

1. General Liability Insurance covering premises and operations, contractual liability insuring the obligations

assumed by Contractor in this Agreement, broad form property damage, personal injury liability and independent



contractor coverages. We require the Occurrence form. “Claims Made” in not acceptable. Limits required are

$1,000,000 for each occurrence.

2. Auto Liability Insurance covering all vehicles, whether owned, hired, or non-owned, including unidentified

trailer, used in providing service under the terms of this Agreement; and covering bodily injury (including death) and

property damage. Liability coverage shall be at least one million dollars ($1,000,000) combined single limit, provided

however Carrier reserves the right to require Contractor to carry higher coverage. This insurance shall provide coverage

to all persons and property including, without limitation, Contractor and Carrier and their employees, agents and

servants. Contractors using Carrier’s Trailer Equipment are required to carry additional insurance for non-owned

equipment in the amount of $60,000.

3. Worker's Compensation and Employer's Liability insurance with limits not less than those required pursuant to

state law(s) in states in which the Contractor is operating. If Contractor is an owner-operator and therefore not required

to carry Worker's Compensation insurance, Contractor will produce and execute a Declaration of Independent

Contractor Status Form acceptable to the Carrier.

4. Cargo Insurance coverage shall be at least $10,000 per occurrence.

5. All such insurance shall provide coverage on an "occurrence" basis and shall be primary coverage. Any other

coverage and other insurance, including any insurance of Carrier, shall be excess coverage and insurance for any loss

arising out of or relating to the operations of Contractor under this Agreement. All insurance policies providing such

coverage shall name Carrier as an additional insured, with coverage by the Contractor being primary and non-

contributory with any insurance or self-insurance carried by the Carrier.

6. All insurance policies shall provide coverage for all legal liability of Contractor, including without limitation, any

contractual liability assumed pursuant to the terms of this Agreement.

7. Contractor will supply Carrier with certificates of insurance for all policies providing the coverage hereinabove

required; said certificates shall require that issuing companies provide thirty (30) days advance written notice of

cancellation to Carrier. Such certificates shall be substantially in accordance with those attached as an exhibit to this

Agreement. Contractor agrees to obtain the written consent (to the insurance, indemnity and other applicable

provisions hereof) from all insurers who have or will issue a policy or policies which might be applicable to a loss

hereunder and, if required, all named insureds on said policy or policies.

8. If any coverage provided hereunder is subject to deductibles, Contractor shall be liable to Carrier for such

deductibles. The insurance requirements set forth in this Section 9 shall not be limited by, nor shall they limit, the

indemnity requirements set forth elsewhere in this Agreement.

9. Contractor shall defend, indemnify and hold harmless Carrier, General Contractor(s) and Owner(s), including

their officers, directors, agents, employees, affiliates, parents and subsidiaries, and each of them, of and from any and



all claims, demands, causes of action, damages, costs, expenses, actual attorneys' fees, consultants fees, expert fees,

losses or liability, in law or in equity, of every kind and nature whatsoever arising out of or related to or in connection

with Contractor's performance under this Agreement for, but not limited to

a. Personal injury, including, but not limited to, bodily injury, emotional injury, sickness or disease, or

death to person, including, but not limited to, any employees or agents of Contractor, Carrier, General

Contractor(s) and Owner(s) and/or damage to property of anyone (including loss of use thereof), caused or

alleged to be caused in whole or in part by any act or omission of Contractor or anyone directly or indirectly

employed by Contractor or anyone for whose acts Contractor may be liable regardless of whether such personal

injury or damage is caused by and regardless of the theory of liability asserted against an indemnified party.

b. Property damage including, but not limited to, damage to both real and personal property, physical

damage to any property, whether or not such property was manufactured by Carrier, General Contractor(s) or

Owner(s), costs to repair defects in property, diminution in property value, loss of use, loss of economic value,

consequential losses, and any other damages associated with damage to, destruction of, defects in, or loss of

real or personal property, regardless of whether such damage is caused by a party indemnified hereunder and

regardless of the theory of liability asserted against an indemnified party.

c. Penalties imposed on account of the violation of any law, order, citation, rule, regulation, standard,

ordinance, or statute, caused in whole or in part by the action or inaction of Contractor.

d. Claims or liens for labor performed or materials used or furnished to be used on the job, and all

incidental or consequential damages resulting to General Contractor(s) or Owner(s) from such claims or liens.

e. Failure of Contractor to comply with any provisions of this Agreement regarding insurance.

f. Any violation of infraction by Contractor or its employees, agents or servants of any law, order, citation,

rule, regulation, standard, ordinance, or statute in any way relating to the occupational health or safety of

employees, including, but not limited to, the use of Carrier's Trailer Equipment, General Contractor(s), Owner(s),

or others' equipment.

The indemnification provisions of subsections “a” through “f” above shall extend to claims occurring after this

Agreement is terminated as well as while it is in force. Such indemnity provisions apply regardless of any active and/or

passive negligent act or omission of Carrier, General Contractor(s) or any other indemnified person. Contractor,

however, shall not be obligated under this Agreement to indemnify Carrier if any claims arise from the sole negligence

or willful misconduct of Carrier or its agents, employees, or independent contractors who are directly responsible to

Carrier. Contractor shall:



a. At Contractor's own cost, expense, and risk, defend all claims that may be brought or instituted by third

person, including, but not limited to, governmental agencies or employees, agents or servants of Contractor,

against Carrier or its employees or agents, or any of them.

b. Pay and satisfy any judgment or decree that may be entered against Carrier, or its employees or agents,

or any of them, arising out of any such claim; and/or

c. Reimburse Carrier or its employees or agents for any and all legal or investigative expense incurred by

any of them in connection herewith or in enforcing any indemnity granted in the Agreement.

The indemnities set forth in this Section 10 shall not be limited by the insurance requirements set forth in this

Agreement.

Section 11: Payment for Services

Prior to, or within a reasonable time after commencement of work on a project, Carrier and Contractor shall agree on

the rate of compensation for the project. Rates for each project may be memorialized in writing by Carrier to Contractor,

provided however, that negotiation (cashing, depositing or otherwise endorsing) by Contractor of Carrier's check

covering work done on a project shall be binding and conclusive proof of Carrier and Contractor's Agreement to the rate,

amount and type of compensation paid in said check.

Contractor shall record weights, time, volumes and/or loads on a freight bill as required by Carrier for work performed.

Upon the conclusion of each workday, Contractor shall obtain on the freight bill the signature of an authorized jobsite

representative. The signed freight bill shall be forwarded to Carrier within 24 hours. Freight bills submitted after 24

hours will be subject to a processing delay, and late payment. Freight bills submitted 24 hours or more after completion

of the workday will be considered a waiver of any right to payment if such delays limit Carrier’s right to payment from

the Shipper.

Contractor will be paid only for the work included on the freight bill signed by an authorized jobsite representative.

Carrier has no obligation to pay Contractor amounts not supported by a properly completed freight bill. Carrier has no

obligation to pay Contractor for any work related to a freight bill which is false and/or fraudulent.

Carrier has no obligation to pay Contractor for any work unless a properly completed freight bill is submitted to Carrier

within 24 hours after completion of the workday covered by the freight bill. If Carrier is not paid from its end Customer

due to billing delays caused by Contractor, Carrier shall have no liability to Contractor for payment. Carrier will make



best efforts to pay Contractor for loads submitted after the deadline, but only in the event Carrier is paid from its end

Customer. Carrier shall have no liability to Contractor on any disputed payment unless Contractor notifies Carrier in

writing, within 7 days of receipt of the weekly Contractor Settlement Statement, that the payment received did not

cover all work performed in the previous week and that additional monies are due to Contractor.

Contractor may purchase parts, fuel, oil, tires, and other supplies from any supplier it chooses. With prior written

approval of Carrier, Contractor may purchase such supplies from the Carrier to be charged to the account of Contractor.

In such cases, Contractor authorizes Carrier to deduct such charges from payments to be made to Contractor. Carrier

reserves the right to additional charges for said purchases to cover Carrier's administrative expenses.

Except as provided herein, payment for freight bills received timely by Carrier will be made pursuant to the “Payment

Terms Agreement” and “Payment Type Election” addenda to this agreement. In the event the payment date falls on a

weekend or holiday, payment will be made on the next workday.

Payment otherwise due to Contractor may be withheld in whole or in part by Carrier as provided herein; including

without limitation, on account of Contractor's defective performance not remedied, improper insurance, claims filed or

reasonable evidence indicating probability of filing of claims against Contractor or Carrier, failure of Contractor to make

payments to its employees or subhauler, or for material, supplies, labor, or a reasonable doubt that the work can be

completed for the balance then unpaid. If the foregoing causes are resolved to Carrier’s satisfaction, the withheld

payments shall promptly be made. If the said causes are not so resolved, Carrier may, but is not required to, rectify the

same at Contractor’s expense.

Carrier is hereby expressly granted the right to setoff of any payments due to Contractor under the provisions of this

Agreement against any other obligations that may be due from Contractor to Carrier.

Section 12: Termination of Agreement

This Agreement shall commence on the date of execution and shall continue in effect for a period of one year from the

execution date. If not terminated under the provisions contained herein, the Agreement will be automatically renewed

for successive one year terms under the same terms, conditions and requirements as the initial Agreement. This

Agreement may be terminated at an earlier date only in accordance with the following provisions:



1. At any time upon the mutual written consent of the parties hereto.

2. By either party with cause, by written notice of termination to the other party, if the other party commits a

material breach or default of the terms of this Agreement. Said notice shall specify the breach relied upon and the date

of termination, which termination may be effective immediately upon service of said notice.

3. Carrier reserves the right to terminate this Agreement immediately for any of the following reasons including,

but not limited to:

a. Contractor's causing or allowing excessive damage to Carrier's Equipment.

b. Contractor's improper maintenance of Contractor's Equipment.

c. Contractor's failure to follow applicable laws of the United States and the state they are operating in.

d. Contractor’s failure to obey lawful and proper orders in carrying out work assignments and failure to

complete a job assignment in accordance with the terms of such assignment.

e. Contractor's failure to maintain the insurance required under this Agreement.

f. Contractor's failure to notify Carrier when Contractor, its employees, agents or servants are

involved in an accident, without regard to fault or the nature and/or severity of the accident.

g. Contractor's loss of driving privilege and/or disqualification from driving.

h. Contractor's submission of freight bills which are false and/or fraudulent.

i. Contractor’s failure to comply with the requirements of Carrier’s customers.

j. Contractor’s failure to comply with Carrier’s service, integrity or conduct requirements.

k. Contractor’s sharing of Confidential Information or breach of duties with respect to the provisions of

Section 3, Confidentiality/Non-Competition.

Upon termination of this Agreement, Contractor shall complete delivery of any shipment it may be engaged in

transporting at the time of said termination. Should Contractor fail to complete delivery of any shipment and/or fail to

return all of Carrier's Trailer Equipment to Carrier's specified location, Contractor will be liable for all expenses incurred

by Carrier to complete delivery of shipment and to recover its Trailer Equipment. Pending any final settlement, Carrier is

authorized to retain sums as deemed necessary by Carrier to cover Contractor’s liability to Carrier.

Section 13: Miscellaneous

1. By agreeing to provide services requested by Carrier, and/or by undertaking such services, Contractor warrants

that all conditions precedent in this Agreement have been satisfied and shall remain effective for the term of this



Agreement. Contractor shall defend, indemnify and hold Carrier harmless from and against any damages, threatened or

actual, resulting from a breach of these warranties.

2. If any provision in this Agreement is deemed invalid, void, or unenforceable, the remaining provisions of this

Agreement will nevertheless continue in full force and effect without being deemed impaired or invalidated in any way.

3. The failure of Carrier to enforce at any time any of the provisions of this Agreement, or to exercise any option

herein provided, or to require at any time performance by Contractor of any of the provisions herein, shall in no way be

construed to be a waiver of such provisions, nor in any way affect the validity of this Agreement or any part thereof, or

the right of the Carrier to thereafter enforce each and every such provision.

4. The laws of the State of Colorado as to interpretation and performance shall govern this Agreement. Each party

has had the opportunity to be represented by independent counsel of its own choice throughout all negotiations

preceding execution of this Agreement and addenda to this Agreement, the parties agree that the terms of this

Agreement shall be given a neutral interpretation and any ambiguities or uncertainty in the Agreement shall not be

construed against either party.

5. This Agreement constitutes the entire agreement and understanding between the parties and shall not be

modified, altered, changed or amended in any respect unless done in writing and signed by both parties. This

Agreement shall supersede, replace and take precedence over any prior oral or written agreements regarding the

subject matter hereof between the parties hereto, and shall not be modified, altered, changed or amended in any

respect unless done in writing and signed by both parties.

6. This Agreement shall bind and inure to the benefit of the respective heirs, representative, successors and assigns

of the parties hereto. This Agreement may not be assigned by either party without the prior written consent of the

other, which consent may be withheld for any reason or no reason.

7. Any and all notices between the parties hereto shall be in writing and shall be deemed duly served when

personally delivered to the party or, in lieu of such personal service, one (1) day after deposit in the United States Mail

certified mail, return receipt requested, and addressed to such party at the address shown above.

8. Time is of the essence in the Agreement, both as to the terms and the services to be rendered hereunder.



9. This Agreement may be executed in one or more counterparts, each of which shall be deemed an original, but

all of which together shall constitute one and the same agreement. For purposes of this Agreement, the facsimile or

scanned signatures of any party hereto shall constitute and be deemed an original signature.

IN WITNESS WHEREOF, authorized representatives of the parties to this Agreement have executed it, including the

associated Exhibits, incorporated as a part of this Agreement, on this ___ day of ___________________, 20___ .

CARRIER CONTRACTOR

Transpro, Inc. ______________________________________

___________________________________ ______________________________________ Signature Signature ___________________________________ ______________________________________ Printed Name Printed Name ___________________________________ ______________________________________ Title Title



INDEPENDENT CONTRACTOR DOCUMENT CHECKLIST

� Completed W-9 Form

� Completed Payment Type Election Form

� Completed Payment Terms Agreement

� Certificate of Insurance, naming Transpro, Inc. as Additional Insured

� Certificate of Worker’s Compensation Insurance (if you have more than 1 truck)

� Declaration of Independent Contractor Status (if you are an owner-operator)

� Documentation of USDOT number

� Documentation of MC number

� Completed Contractor Information Form

� Trailer Lease Agreement (if applicable)

� Annual Inspections for Equipment (trucks/trailers)

� Registrations for Equipment (trucks/trailers)

Use this checklist to make sure you are preparing all the required forms. Once you have everything on this

checklist, you can drop it by our office or scan and email it to [email protected].




IDENTIFICATION OF INDEPENDENT CONTRACTOR INFORMATION

CONTACT INFORMATION

Company Name: __________________________________________________________________________________

Mailing Address: __________________________________________________________________________________

__________________________________________________________________________________________________

Federal ID Number: _________________________________________________________________________________

Federal Motor Carrier (MC) Number: ___________________________________________________________________

DOT Number: ______________________________________________________________________________________

Are you apportioned and licensed to work in other states? ☐ Yes ☐ No

Primary Contact: ___________________________________________________________________________________

Primary Phone #: __________________________________________________________________________________

Alternate Contact: __________________________________________________________________________________

Alternate Phone #: _________________________________________________________________________________

Email Address: _____________________________________________________________________________________

VEHICLE INFORMATION

Number of Trucks: __________________________________________________________________________________

Do you have your own trailers? ☐ Yes ☐ No

Please check all that apply:

Blower Wet Kit PTO Types and number of Trailers (if applicable)

Truck 1 ☐ ☐ ☐ Pneumatic ________________

Truck 2 ☐ ☐ ☐ Belly Dump ________________

Truck 3 ☐ ☐ ☐ Side Dump ________________

Truck 4 ☐ ☐ ☐ End Dump ________________

Truck 5 ☐ ☐ ☐ Flatbed ________________

Lowboy ________________



PAYMENT TYPE ELECTION

______________________________________, (Contractor) enter into this payment agreement with Transpro Burgener

Trucking (Company) and elect to have settlement payments from the Company be made via:

Method:

� Paper Check

� ACH Transfer

ACH AUTHORIZATION (Please read carefully before signing)

By signing this form you agree: to all conditions/fees imposed by your bank for all designated actions; you are allowed

to make deposits into checking and savings accounts. Attach a voided check for verification of the ACH bank routing

number and bank account number for the account listed below. Please allow one calendar week for the ACH transfer to

begin. If you change banks or accounts, you are fully responsible for immediately notifying the Company of the change.

I authorize and agree that in the event the Company deposits funds erroneously into my account, the Company may

debit my account for an amount not to exceed the original amount of the erroneous credit.

Account Holder Name: ______________________________________________ Date: ______________

Bank Name: ______________________________________________________

City: __________________________________ State: _____________ Phone: ____________________

ABA Routing Number: ___ ___ ___ ___ ___ ___ ___ ___ ___

Account Number: __________________________________

Type of Account:

� Checking Account

� Savings Account

Signature: _________________________________________ Date: ____________________



PAYMENT TERMS AGREEMENT ______________________________________, (Contractor) enter into this payment agreement with Transpro Burgener

Trucking (Company) and elect to have settlement payments from the Company be made with the following terms:

� Standard Terms (45 Days) Settlement payments are made weekly for the previous week (Sunday through Saturday). If you elect Standard Payment

Terms, you understand and agree that Transpro Burgener Trucking will send you a check or ACH transfer so that you

receive it approximately 45 days after the end of the week for which services were rendered. Election periods run from

July 1 through December 31 and January 1 through June 30. Once an election has been made, it cannot be changed

until the next election period. If no decision is made for subsequent election periods, payment terms will revert to

Standard Terms (45 days).

� Quick Pay / Factoring Terms (7 days)

For Quick Pay terms, we will settle your payment for any given Sunday-Saturday period on the following Wednesday.

We process ACH transactions with our bank that day; however, depending on your bank’s policies, you may have the

funds available the same day (Wednesday) or the following day (Thursday). If you elect Quick Pay Terms, you

understand and agree that Transpro Burgener Trucking will automatically factor all settlement payments for the entire

election period. Election periods run from July 1 through December 31 and January 1 through June 30. Once an election

has been made, it cannot be changed until the next election period. If no decision is made for subsequent election

periods, payment terms will revert to Standard Terms (45 days). If you elect Quick Pay Terms, you understand that you

will pay a fee of 4.5% of your total settlement, and that fee will be netted against your settlement payment.

Enrollment Period (select one):

� January – June, 2018 � July – December, 2018

_____________________________________ ___________________ Signature Date _____________________________________ Print Name and Title



TRAILER USAGE FORM

Trailer Description

Unit Number: ________________

Trailer Type: ________________

Make: ________________

Model: ________________

Year: ________________

VIN Number: ________________

Plate Number: ________________

Trailer Check-Out Information

Yes No

Photo Taken? ☐ ☐

Current Registration? ☐ ☐

Hotline? ☐ ☐

Product Hoses? ☐ ☐ Number of Hoses ___________

This form is governed by the terms of the Independent Contractor Agreement specifically, but not limited to, Section 6.

Contractor agrees to pay a fee equal to 10% of the settlement amounts for services completed for the Carrier as a fee to

utilize Carrier’s trailers. Contractor also agrees to the maintenance and inspection requirements contained in Section 6

of the Agreement.

Signature: ___________________________________ Date: ________________________

Name & Title: ___________________________________



FEDERAL ELECTRONIC LOGGING DEVICE (ELD)

COMPLIANCE CERTIFICATION

The Federal Motor Carrier Safety Administration (FMCSA) has amended the Federal Motor Carrier Safety Regulations (FMCSRs) to establish: Minimum performance and design standards for hours-of-service (HOS) electronic logging devices (ELDs); requirements for the mandatory use of these devices by drivers currently required to prepare HOS records of duty status (RODS); requirements concerning HOS supporting documents; and measures to address concerns about harassment resulting from the mandatory use of ELDs. The requirements for ELDs will improve compliance with the HOS rules.

I, ____________________________ (Company Officer) hereby certify that my company, _____________________________ (Name of Company) has obtained, installed and is utilizing an Electronic Logging Device (ELD) in accordance with new Federal regulations in Part 395, 49 CFR 395.8(a) effective December 18, 2017.

Signature: ___________________________________ Date: ________________________

Name & Title: ___________________________________

Internal Use Only:

Verified: ________

Date: __________

Form W-9(Rev. December 2014)Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Give Form to the

requester. Do not

send to the IRS.

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2.

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification; check only one of the following seven boxes:

Individual/sole proprietor or single-member LLC

C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)

Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner.

Other (see instructions)

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):Exempt payee code (if any)

Exemption from FATCA reporting

code (if any)(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.)

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter.

Social security number

– –

orEmployer identification number

–

Part II Certification

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.

Sign Here

Signature of

U.S. person Date

General InstructionsSection references are to the Internal Revenue Code unless otherwise noted.

Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at www.irs.gov/fw9.

Purpose of Form

An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following:

• Form 1099-INT (interest earned or paid)

• Form 1099-DIV (dividends, including those from stocks or mutual funds)

• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)

• Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)

• Form 1099-S (proceeds from real estate transactions)

• Form 1099-K (merchant card and third party network transactions)

• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)

• Form 1099-C (canceled debt)

• Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2.

By signing the filled-out form, you:

1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),

2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and

4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information.

Cat. No. 10231X Form W-9 (Rev. 12-2014)

Form W-9 (Rev. 12-2014) Page 2

Note. If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9.

Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:

• An individual who is a U.S. citizen or U.S. resident alien;

• A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States;

• An estate (other than a foreign estate); or

• A domestic trust (as defined in Regulations section 301.7701-7).

Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners’ share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income.

In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States:

• In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity;

• In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and

• In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust.

Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities).

Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a “saving clause.” Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes.

If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items:

1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien.

2. The treaty article addressing the income.

3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions.

4. The type and amount of income that qualifies for the exemption from tax.

5. Sufficient facts to justify the exemption from tax under the terms of the treaty article.

Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption.

If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233.

Backup Withholding

What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 28% of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.

You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return.

Payments you receive will be subject to backup withholding if:

1. You do not furnish your TIN to the requester,

2. You do not certify your TIN when required (see the Part II instructions on page 3 for details),

3. The IRS tells the requester that you furnished an incorrect TIN,

4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or

5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup withholding. See Exempt payee code on page 3 and the separate Instructions for the Requester of Form W-9 for more information.

Also see Special rules for partnerships above.

What is FATCA reporting?

The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code on page 3 and the Instructions for the Requester of Form W-9 for more information.

Updating Your Information

You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies.

Penalties

Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.

Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty.

Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.

Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties.

Specific Instructions

Line 1

You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return.

If this Form W-9 is for a joint account, list first, and then circle, the name of the person or entity whose number you entered in Part I of Form W-9.

a. Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name.

Note. ITIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1a. This should also be the same as the name you entered on the Form 1040/1040A/1040EZ you filed with your application.

b. Sole proprietor or single-member LLC. Enter your individual name as shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade, or “doing business as” (DBA) name on line 2.

c. Partnership, LLC that is not a single-member LLC, C Corporation, or S Corporation. Enter the entity's name as shown on the entity's tax return on line 1 and any business, trade, or DBA name on line 2.

d. Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on line 2.

e. Disregarded entity. For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a “disregarded entity.” See Regulations section 301.7701-2(c)(2)(iii). Enter the owner's name on line 1. The name of the entity entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided on line 1. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on line 2, “Business name/disregarded entity name.” If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN.


Line 2

If you have a business name, trade name, DBA name, or disregarded entity name, you may enter it on line 2.

Line 3

Check the appropriate box in line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box in line 3.

Limited Liability Company (LLC). If the name on line 1 is an LLC treated as a partnership for U.S. federal tax purposes, check the “Limited Liability Company” box and enter “P” in the space provided. If the LLC has filed Form 8832 or 2553 to be taxed as a corporation, check the “Limited Liability Company” box and in the space provided enter “C” for C corporation or “S” for S corporation. If it is a single-member LLC that is a disregarded entity, do not check the “Limited Liability Company” box; instead check the first box in line 3 “Individual/sole proprietor or single-member LLC.”

Line 4, Exemptions

If you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space in line 4 any code(s) that may apply to you.

Exempt payee code.

• Generally, individuals (including sole proprietors) are not exempt from backup withholding.

• Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends.

• Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions.

• Corporations are not exempt from backup withholding with respect to attorneys' fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form 1099-MISC.

The following codes identify payees that are exempt from backup withholding. Enter the appropriate code in the space in line 4.

1—An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2)

2—The United States or any of its agencies or instrumentalities

3—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities

4—A foreign government or any of its political subdivisions, agencies, or instrumentalities

5—A corporation

6—A dealer in securities or commodities required to register in the United States, the District of Columbia, or a U.S. commonwealth or possession

7—A futures commission merchant registered with the Commodity Futures Trading Commission

8—A real estate investment trust

9—An entity registered at all times during the tax year under the Investment Company Act of 1940

10—A common trust fund operated by a bank under section 584(a)

11—A financial institution

12—A middleman known in the investment community as a nominee or custodian

13—A trust exempt from tax under section 664 or described in section 4947

The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13.

IF the payment is for . . . THEN the payment is exempt for . . .

Interest and dividend payments All exempt payees except for 7

Broker transactions Exempt payees 1 through 4 and 6 through 11 and all C corporations. S corporations must not enter an exempt payee code because they are exempt only for sales of noncovered securities acquired prior to 2012.

Barter exchange transactions and patronage dividends

Exempt payees 1 through 4

Payments over $600 required to be reported and direct sales over $5,0001

Generally, exempt payees 1 through 52

Payments made in settlement of payment card or third party network transactions

Exempt payees 1 through 4

1 See Form 1099-MISC, Miscellaneous Income, and its instructions.

2 However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney reportable under section 6045(f), and payments for services paid by a federal executive agency.

Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements. A requester may indicate that a code is not required by providing you with a Form W-9 with “Not Applicable” (or any similar indication) written or printed on the line for a FATCA exemption code.

A—An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37)

B—The United States or any of its agencies or instrumentalities

C—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities

D—A corporation the stock of which is regularly traded on one or more established securities markets, as described in Regulations section 1.1472-1(c)(1)(i)

E—A corporation that is a member of the same expanded affiliated group as a corporation described in Regulations section 1.1472-1(c)(1)(i)

F—A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state

G—A real estate investment trust

H—A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940

I—A common trust fund as defined in section 584(a)

J—A bank as defined in section 581

K—A broker

L—A trust exempt from tax under section 664 or described in section 4947(a)(1)

M—A tax exempt trust under a section 403(b) plan or section 457(g) plan

Note. You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed.

Line 5

Enter your address (number, street, and apartment or suite number). This is where the requester of this Form W-9 will mail your information returns.

Line 6

Enter your city, state, and ZIP code.

Part I. Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.

If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN.

If you are a single-member LLC that is disregarded as an entity separate from its owner (see Limited Liability Company (LLC) on this page), enter the owner’s SSN (or EIN, if the owner has one). Do not enter the disregarded entity’s EIN. If the LLC is classified as a corporation or partnership, enter the entity’s EIN.

Note. See the chart on page 4 for further clarification of name and TIN combinations.

How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local SSA office or get this form online at www.ssa.gov. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov/businesses and clicking on Employer Identification Number (EIN) under Starting a Business. You can get Forms W-7 and SS-4 from the IRS by visiting IRS.gov or by calling 1-800-TAX-FORM (1-800-829-3676).

If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester.

Note. Entering “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon.

Caution: A disregarded U.S. entity that has a foreign owner must use the appropriate Form W-8.


Part II. Certification

To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if items 1, 4, or 5 below indicate otherwise.

For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on line 1 must sign. Exempt payees, see Exempt payee code earlier.

Signature requirements. Complete the certification as indicated in items 1 through 5 below.

1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification.

2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form.

3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification.

4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. “Other payments” include payments made in the course of the requester’s trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments made in settlement of payment card and third party network transactions, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations).

5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification.

What Name and Number To Give the Requester

For this type of account: Give name and SSN of:

1. Individual The individual2. Two or more individuals (joint

account)The actual owner of the account or, if combined funds, the first individual on the account1

3. Custodian account of a minor (Uniform Gift to Minors Act)

The minor2

4. a. The usual revocable savings trust (grantor is also trustee) b. So-called trust account that is not a legal or valid trust under state law

The grantor-trustee1

The actual owner1

5. Sole proprietorship or disregarded entity owned by an individual

The owner3

6. Grantor trust filing under Optional Form 1099 Filing Method 1 (see Regulations section 1.671-4(b)(2)(i)(A))

The grantor*

For this type of account: Give name and EIN of:

7. Disregarded entity not owned by an individual

The owner

8. A valid trust, estate, or pension trust Legal entity4

9. Corporation or LLC electing corporate status on Form 8832 or Form 2553

The corporation

10. Association, club, religious, charitable, educational, or other tax-exempt organization

The organization

11. Partnership or multi-member LLC The partnership12. A broker or registered nominee The broker or nominee

13. Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments

The public entity

14. Grantor trust filing under the Form 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulations section 1.671-4(b)(2)(i)(B))

The trust

1 List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished.

2 Circle the minor’s name and furnish the minor’s SSN.

3 You must show your individual name and you may also enter your business or DBA name on the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN.

4 List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules for partnerships on page 2.

*Note. Grantor also must provide a Form W-9 to trustee of trust.

Note. If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.

Secure Your Tax Records from Identity Theft

Identity theft occurs when someone uses your personal information such as your name, SSN, or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund.

To reduce your risk:

• Protect your SSN,

• Ensure your employer is protecting your SSN, and

• Be careful when choosing a tax preparer.

If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter.

If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039.

For more information, see Publication 4535, Identity Theft Prevention and Victim Assistance.

Victims of identity theft who are experiencing economic harm or a system problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD 1-800-829-4059.

Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft.

The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts.

If you receive an unsolicited email claiming to be from the IRS, forward this message to [email protected]. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration (TIGTA) at 1-800-366-4484. You can forward suspicious emails to the Federal Trade Commission at: [email protected] or contact them at www.ftc.gov/idtheft or 1-877-IDTHEFT (1-877-438-4338).

Visit IRS.gov to learn more about identity theft and how to reduce your risk.

Privacy Act Notice

Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.

of 3 ZAUCCIF007 09/15

This form is not valid unless a signed and notarized copy of the form is returned to Pinnacol Assurance. Keep the original for your records and send a copy to Pinnacol. You can do this the following ways:

• Mail: Pinnacol Assurance P.O. Box 469011 Denver, CO 80246-9011

• Email: [email protected]

• Fax: 303.631.5000

Declaration of Independent Contractor Status Form

According to the Colorado Workers’ Compensation Act, a person is an independent contractor, not an employee, if both of the following statements are true.

1. He/she is free from control and direction in the performance of the service (unless control is exercised under the requirement of any state or federal statute or regulation).

2. He/she is customarily engaged in an independent trade, occupation, profession, or business related to the services performed.

The Colorado Workers’ Compensation Act also outlines nine criteria (listed on page 2) to help determine whether or not the above statements are true. For an individual to be considered an independent contractor, he/she must meet only those criteria that are appropriate to the situation. He/she does not need to meet all of the nine criteria.

This Declaration of Independent Contractor Status Form documents the business relationship as defined in the Colorado Workers’ Compensation Act. It is the responsibility of our policyholders and their independent contractor(s) to correctly and truthfully complete this form. Pinnacol Assurance will accept this form only when it is initialed where applicable, signed, and notarized by both parties. If you do not understand this form, do not sign it.

If you have any questions, please contact your Pinnacol Assurance underwriter at 303.361.4000 or 800.873.7242.

Please make copies of this form as needed. You should complete this form only once for each independent contractor for the lifetime of your Pinnacol policy or until the business relationship changes.


Declaration of Independent Contractor Status Form

We certify UNDER PENALTY OF PERJURY that (insert contractor’s name and trade name below):

Name: __________________________________________ Trade name: _________________________________

Performing (type of work): _______________________________________________________________________

Federal Employer Identification #: _________________________________________________________________

Address: _____________________________________________________________________________________

Phone: ______________________________________________________________________________________

Is an independent contractor (IC) and is not an employee of the following policyholder (PH):

Policyholder’s name: ___________________________________________________________________________

Address: _____________________________________________________________________________________

Policy #: ________________________________________ Phone: ______________________________________

We also certify, by OUR initials WHERE APPLICABLE, that the above business for which the above individual performs services meet the following criteria: IC PH. 1. The business DOES NOT require the individual to work ONLY for the business for whom services

are performed (except that the individual may DECIDE to work only for the business for a definite period);

IC PH. 2. The business DOES NOT establish a quality standard for the individual (except that the business may provide plans and specifications regarding work but cannot oversee the actual work or instruct the individual as to how work will be performed);

IC PH. 3. The business DOES NOT pay the individual a salary or an hourly rate instead of a fixed or contract rate;

IC PH. 4. The business DOES NOT terminate the work or the service provided during the contract period unless the individual violates the terms of the contract or fails to produce a result that meets the specifications of the contract;

IC PH. 5. The business DOES NOT provide more than minimal training for the individual; IC PH. 6. The business DOES NOT provide tools or benefits to the individual (except that materials and

equipment may be supplied); IC PH. 7. The business DOES NOT dictate the time of performance (except that a completion schedule and a

range of agreeable work hours may be established); IC PH. 8. The business DOES NOT pay the individual personally instead of making payment or checks payable

to the trade or business name of the individual; IC PH. 9. The business DOES NOT combine the business operations in any way with the individual’s business

operations instead of maintaining all such operations separately and distinctly.

Do not forget to complete page 3 of this form, which contains the Certification by the Independent Contractor. This certification must be signed and notarized.


Certification by Independent Contractor

The independent contractor understands that he/she: • Will not be entitled to any workers’ compensation benefits in the event of injury. • Is obligated to pay all federal and state income tax on all money earned while performing

services for the business. • Is required to provide workers’ compensation insurance for all workers that he/she hires. Signature: ____________________________________________ Title: ___________________________________

Last four digits of Social Security #: XXX-XX-_____________(please do not provide us with your complete Social Security #)

Acceptance of the Independent Contractor named on this form does not change any party’s responsibility under the Workers’ Compensation Act. If individuals or organizations hired or contracted by the Independent Contractor are not covered by other workers’ compensation insurance, the policyholder specified on this form will be charged premium for coverage of those individuals or organizations.

Notary Public State of Colorado )

)

County of ) ___________________________________________

Subscribed and sworn before me by: _______________________________

This ________ day of ____________________________ , _____________

Commission expires: ____________________________________________

Signature: ____________________________________________________

________________________________________________________________________________

Certification By Pinnacol Policyholder I certify that I am authorized by the business listed above to state that all of the information on this form is true and accurate. I understand that if the above person does not qualify for independent contractor status, the proper premium can be assessed.

Signature: ____________________________________________ Title: ___________________________________

Policy # or Federal Employer Identification #: ________________________________________________________

Notary Public State of Colorado )

)

County of )__________________________________________ _

Subscribed and sworn before me by: _______________________________

This ________ day of ____________________________ , _____________

Commission expires: ____________________________________________

Signature: ____________________________________________________

INDEPENDENT CONTRACTOR INFORMATION PACKET · 2017-12-13 · INDEPENDENT CONTRACTOR PACKET...

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Transcript of INDEPENDENT CONTRACTOR INFORMATION PACKET · 2017-12-13 · INDEPENDENT CONTRACTOR PACKET...