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The Pinnacol Contractor Status form is a crucial document designed to clarify the nature of the working relationship between businesses and individuals who provide services as independent contractors. It plays a significant role in determining whether a contractor qualifies as an independent contractor, rather than an employee, under the Colorado Workers' Compensation Act. This form stipulates two fundamental conditions: first, the contractor must exercise autonomy in completing their work, free from the control and direct oversight typically associated with employment; second, the contractor should customarily engage in a trade or profession that relates to the services they render. To facilitate this classification, the Act outlines nine specific criteria to guide businesses and individuals in establishing whether these conditions are met. Importantly, not all criteria need to be fulfilled; only those applicable to the specific situation should be considered. The responsibility to complete this form truthfully lies with both the policyholders and the contractors involved. Proper execution requires not only the initials and signatures but also notarization to ensure validity. It is also recommended that copies of this form are retained for future reference, as it only needs to be completed once per contractor for the duration of the Pinnacol policy, unless the business relationship changes. Understanding the requirements and implications of this form is essential, especially considering its importance in establishing a legal framework that guides workers’ compensation coverage and liabilities.

Pinnacol Contractor Status Example

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 a member of Pinnacol’s customer service team 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.

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:

Email: customer_service@pinnacol.com

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

Fax: 303.361.5000

Page 1 of 3 ZAUCCIF007 03/17

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.

Page 2 of 3 ZAUCCIF007 03/17

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: ____________________________________________________

Page 3 of 3 ZAUCCIF007 03/17

Get Pinnacol Contractor Status PDF Form

Form Characteristics

Fact Name Description
Governing Law This form is governed by the Colorado Workers’ Compensation Act, which outlines the legal framework for determining independent contractor status.
Independent Contractor Definition A person is an independent contractor if he/she is free from control in the performance of services and is engaged in an independent trade or business.
Criteria for Status There are nine criteria included in the form that help assess whether the statements about independent contractor status are true.
Documentation Requirement The form serves as a record of the business relationship and must be completed truthfully by both the contractor and policyholder.
Completion Obligations Both parties must ensure the form is fully completed, initialed, signed, and notarized for it to be valid.
Notarization Requirement A notarized copy of the form must be submitted to Pinnacol Assurance to validate the independent contractor status.
Duration of Use This form should only be completed once for each contractor for the life of the Pinnacol policy or until the business relationship changes.
Payment Guidelines Payments must be made to the business or trade name of the contractor, not directly to the contractor as an individual.
Tax Responsibilities The independent contractor is responsible for paying all federal and state income taxes on earnings gained during this work.

Guidelines on Utilizing Pinnacol Contractor Status

After you complete the Pinnacol Contractor Status form, it's important to submit it properly to ensure compliance with the requirements outlined in the Colorado Workers' Compensation Act. Make sure that both you and the independent contractor have signed and notarized the form before sending it to Pinnacol Assurance. Remember to keep a copy for your records and to reach out to Pinnacol's customer service if you need assistance.

  1. Obtain the form: Start by downloading or printing the Pinnacol Contractor Status form from the appropriate source.
  2. Fill in contractor information: Provide the contractor’s name, trade name, type of work performed, Federal Employer Identification Number (EIN), address, and phone number in the designated spaces.
  3. Complete policyholder information: Enter the policyholder’s name, address, policy number, and phone number where required.
  4. Initial the criteria: As both the independent contractor and the policyholder, you need to review the nine criteria listed. Initial where applicable to certify that the conditions have been met.
  5. Complete page 3: Fill out the certification by the independent contractor section with their signature, title, and last four digits of their Social Security Number (SSN).
  6. Obtain notarization: Arrange for the notarization of the document by a notary public for both the independent contractor and the policyholder sections.
  7. Submit the form: Send the signed and notarized form to Pinnacol Assurance using one of the following methods: email, mail, or fax. Keep a copy for your records.

What You Should Know About This Form

What is the purpose of the Pinnacol Contractor Status form?

The Pinnacol Contractor Status form serves to document the business relationship between a policyholder and an independent contractor, as defined by the Colorado Workers’ Compensation Act. This form ensures that both parties understand that the contractor is considered an independent worker, not an employee. It helps to clarify responsibilities, tax obligations, and protections under the law, essentially protecting both the contractor and the policyholder in this working arrangement.

Who is responsible for completing the Pinnacol Contractor Status form?

Both the policyholder and the independent contractor are responsible for correctly completing the Pinnacol Contractor Status form. It’s essential that both parties provide accurate and truthful information, as any discrepancies can lead to legal complications or incorrect insurance assessments. Each party must initial where applicable, sign, and notarize the form to ensure its validity.

How should I submit the completed Pinnacol Contractor Status form?

Once the form is completed, signed, and notarized by both parties, it must be returned to Pinnacol Assurance. You have several options for submission: via email at customer_service@pinnacol.com, by mail to Pinnacol Assurance, P.O. Box 469011, Denver, CO 80246-9011, or by fax at 303.361.5000. It’s important to retain the original for your records and send a copy to Pinnacol.

Is there a requirement for how often the Pinnacol Contractor Status form needs to be completed?

This form only needs to be completed once for each independent contractor for the duration of your Pinnacol policy, or until there are modifications in the business relationship. If the relationship changes, a new form will be required. Ensure all information is accurate and that both parties understand the terms before signing, as this protects everyone involved.

Common mistakes

Completing the Pinnacol Contractor Status form requires careful attention to detail. One common mistake people make is skipping the required initials in the areas indicated on the form. Each section has specific requirements that necessitate the initials of both the independent contractor and the policyholder. Failing to initial where appropriate can lead to a rejection of the completed form, causing delays in establishing the independent contractor relationship.

Another frequent error involves inaccurately completing contact information. It's essential to provide accurate names, addresses, and phone numbers for both the contractor and the policyholder. Incorrect or incomplete information can hinder communication and create complications when verifying contractor status. Always double-check these details before submitting the form.

Many individuals also neglect to read through the entire form carefully. Missing important sections, like the Certification by the Independent Contractor on page 3, can render your submission invalid. The third page must be completed with the appropriate signature and notarization. This oversight can delay the acknowledgment of independent contractor status and potentially affect the associated benefits.

People sometimes misunderstand the criteria for independent contractors, leading them to mistakenly assert that individuals qualify when they do not. The form requires certain conditions to be met, but it's important to remember that not all nine criteria must apply in every case. Misapplying these criteria can raise issues later regarding workers' compensation claims and insurance premiums.

Lastly, incomplete notarization is a major pitfall. Individuals often forget that both parties must sign and have their signatures notarized. If either step is skipped, the form will not be valid. Ensuring that a qualified notary public witnesses the signatures correctly is a crucial final step in the process.

Documents used along the form

When dealing with independent contractors, various forms and documents can complement the Pinnacol Contractor Status form. These documents help clarify the relationship, ensure compliance with legal requirements, and protect the rights of all parties involved. Here is a list of commonly used forms along with brief descriptions for each:

  • Independent Contractor Agreement: This document outlines the specific terms and conditions of the working relationship between the independent contractor and the client. It usually includes details about the scope of work, payment terms, and confidentiality obligations.
  • W-9 Form: The W-9 form is used by independent contractors to provide their taxpayer identification number (TIN) to the business that is hiring them. It is essential for tax purposes and reporting income to the IRS.
  • Work Order: A work order specifies the tasks to be performed by the independent contractor. It serves as a project charter and includes timelines, payment details, and deliverables expected upon completion of the work.
  • Invoice: An invoice is a document provided by the independent contractor to the client, detailing the services rendered and the amount due for those services. It usually includes payment terms and due dates.
  • Confidentiality Agreement: This agreement protects sensitive information shared during the course of the contract. It restricts the independent contractor from disclosing proprietary information to others.
  • Insurance Certificates: These certificates provide proof that the independent contractor has the necessary insurance coverage in place, such as general liability or professional liability insurance, to protect against potential claims.
  • Tax Documentation: Various forms documenting taxes, such as 1099 forms, are essential for independent contractors to accurately report their income and avoid tax liabilities at the end of the year.
  • Termination Notice: This document is used when either party wishes to end the agreement before the contracted work is completed. It outlines the reasons and any obligations remaining.
  • Job Description: A job description provides clarity on the roles and responsibilities of the independent contractor. It helps set expectations and aligns both parties on what is needed to complete the work.
  • Compliance Forms: Various compliance forms may be required to ensure that the contractor meets local, state, or federal regulations related to their specific trade or profession.

Collectively, these documents enhance the integrity of the working relationship between independent contractors and clients. It is crucial for all parties to understand and complete these forms accurately to prevent misunderstandings and ensure a smooth working arrangement.

Similar forms

  • IRS Form SS-8: This form helps determine whether an individual should be classified as an independent contractor or employee for federal tax purposes. Similar to the Pinnacol Contractor Status form, it requires information about the working relationship and the level of control exerted by the employer.
  • Independent Contractor Agreement: This document outlines the terms of engagement between a client and an independent contractor. Like the Pinnacol form, it emphasizes the independence of the contractor and establishes the framework for their services.
  • W-9 Form: This form is used by individuals providing services in a non-employee capacity to ensure proper tax classification. It shares similarities with the Pinnacol form in that it affirms the contractor's status and provides relevant business information.
  • Form 1099-MISC: This tax form is issued to report income paid to independent contractors. Both forms serve to document the business relationship and classify the individual as not being an employee.
  • Certificate of Insurance (COI): A COI provides proof of insurance coverage for independent contractors. This document is similar as it reinforces the independent nature of the contractor while protecting the hiring entity against liabilities.
  • State Contractor Registration Application: This application is often required for individuals operating as contractors in various industries. Both forms establish the legitimacy and status of individuals as independent contractors in the context of state regulations.
  • Employment Verification Letter: This letter is often requested by contractors to verify their independent status to potential clients or lenders. Its purpose aligns with the Pinnacol Contractor Status form in confirming that the individual is not classified as an employee.

Dos and Don'ts

When filling out the Pinnacol Contractor Status form, it's important to keep certain things in mind to ensure accuracy and compliance. Here’s a list of dos and don'ts that can guide you:

  • Do read the entire form carefully before starting.
  • Do provide accurate and complete information for both the independent contractor and the policyholder.
  • Do initial where required and ensure both parties sign the form.
  • Do have the form notarized to make it valid.
  • Do keep a copy of the completed form for your records.
  • Don't sign the form if you don't understand any part of it.
  • Don't fill out the form multiple times for the same contractor unless the relationship changes.
  • Don't forget to complete page 3, which includes important certification details.
  • Don't submit the form without first ensuring all sections are filled out correctly.
  • Don't provide your full Social Security number on the form; only the last four digits are needed.

By following these guidelines, you can help ensure a smooth process in completing the Pinnacol Contractor Status form. If you have any questions, don't hesitate to reach out for assistance.

Misconceptions

  • Misconception 1: All independent contractors are exempt from workers’ compensation.

    • Not true. Independent contractors do not receive workers’ compensation benefits as employees do. However, they must maintain their own insurance if they have employees.

  • Misconception 2: Completing the Pinnacol Contractor Status form makes someone an independent contractor.

    • Filling out the form does not automatically confer independent contractor status. The contractor must still meet the criteria defined by the Colorado Workers’ Compensation Act.

  • Misconception 3: Independent contractors can ignore taxes.

    • This is incorrect. Independent contractors are responsible for paying all federal and state income taxes on the earnings they receive from their work.

  • Misconception 4: The form needs to be submitted every time a contractor is hired.

    • The form should only be completed once for each independent contractor, unless the business relationship changes significantly.

  • Misconception 5: All nine criteria must be met for independent contractor status.

    • This is false. A contractor only needs to meet the appropriate criteria for their specific situation, not all nine listed.

  • Misconception 6: Notarization of the form is optional.

    • This is a significant error. The Pinnacol Contractor Status form must be signed and notarized by both parties for it to be valid.

  • Misconception 7: Emailing the form suffices without a signature.

    • Sending the form electronically is not enough. A signed and notarized copy must be sent to Pinnacol Assurance to ensure compliance.

Key takeaways

Filling out the Pinnacol Contractor Status form is a critical step in establishing clear business relationships. Here are seven key takeaways to keep in mind:

  • The form serves to declare a person as an independent contractor, ensuring compliance with the Colorado Workers’ Compensation Act.
  • Both parties must sign and notarize the form for it to be valid. Ensure that initials are provided where applicable.
  • Only one form is needed for each independent contractor, which remains valid throughout the lifetime of your Pinnacol policy unless the relationship changes.
  • Keep a copy of the signed and notarized form for your records. Send a copy to Pinnacol Assurance via email, mail, or fax.
  • Failure to complete the form correctly may lead to misunderstanding of liability and workers’ compensation responsibilities.
  • Understanding the criteria listed in the form can help in accurately representing the nature of the business relationship.
  • Consult Pinnacol’s customer service for clarity if any part of the form is confusing before you proceed with signing.

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