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The form includes business criteria confirming the contractor is not an employee and lists conditions regarding work control, quality standards, compensation, termination, training, tools/benefits, scheduling, and separate operations. It also contains sole proprietor waiver language, independent-contractor certification, and notary sections for both the contractor and the business acceptance statement.","Declaration of Independent Contractor Status Form  \nAmerican Academy certifies under penalty of perjury that: (name/trade name of independent contractor)   performing (type of work)   using the following Social Security or Federal Employer Identification \\#   at the following address:   ; and phone number:   ; is an independent contractor (IC) and is not an employee of the following policy holder (PH):  American Academy  ; Address:  6971 Mira Vista Lane, Castle Pines, CO 80108 Phone:  720-292-5207  Policy \\#:  4132589  \nWe also certify, by our initials where applicable, that the above business for which the above individual performs services meet the following criteria:  \nIC   PH   l. The business DOES NOT require the individual to work ONLY for the business for which services are performed (except that the individual may DECIDE to work only for the business for a definite period);  \nIC   PH   2. The business DOES NOT establish a quality standard for the individual (except that the business may provide plans and specifications  \nregarding work but cannot oversee the actual work or instruct the individual as to how work will be performed);  \nIC   PH   3. The business DOES NOT pay the individual a salary or an hourly rate instead of a fixed or contract rate;  \nIC   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;  \nIC   PH   5. The business DOES NOT provide more than minimal training for the individual;  \nIC   PH   6. The business DOES NOT provide tools or benefits to the individual (except that materials and equipment may be supplied);  \nIC   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);  \nIC   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;  \nIC   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.  \nSOLE PROPRIETOR WAIVER OFCLAIM TO WORKERS’ COMPENSATION  \nIC   PH   The independent contractor certifies by his/her initials that s/he is a sole proprietor without employees and not using subcontractors for the  \nwork being performed, and as such, waives the right to claim workers’ compensation from the policy holder.  \nCERTIFICATION BY INDEPENDENT CONTRACTOR.– to be completed by Independent Contractor in the presence of a Notary Public.  \nThe independent contractor understands that s/he: • will not be entitled to any workers’ compensation benefits in the event of injury;  \n• is obligated to pay all federal and state tax on all money earned while performing services for the business;  \n• is required to provide workers’ compensation insurance for all workers that s/he hires.  \nSignature Title  \nState of Colorado, County of   Subscribed and sworn before me by this (day)   day of (month)   ,(year)    \nNotary Public:   Commission Expires:    \nAcceptance 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.  \nCERTIFICATION BY BUSINESS – to be completed by American Academy and a Notary Public.  \nI 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.  \nSignature Title  \nState of Colorado, Count","cbCainHL8XXaadp3","https://ap.wps.com/l/cbCainHL8XXaadp3","pdf",927843,2,"English","en",105,"# Independent Contractor Declaration\n## Perjury Certification and Contractor Details\n## Independent Contractor Criteria (IC vs. PH)\n## Sole Proprietor Waiver of Workers’ Compensation\n## Certification by Independent Contractor (Notary Public)\n## Acceptance by Business (Notary Public)","[{\"question\":\"What does the independent contractor certify on this form?\",\"answer\":\"The independent contractor certifies the individual is an independent contractor (not an employee) and that the business relationship meets specific criteria regarding control, standards, compensation structure, termination, training, tools/benefits, scheduling, and separate operations.\"},{\"question\":\"When is the contractor certification completed and who must be present?\",\"answer\":\"The certification by the independent contractor must be completed in the presence of a Notary Public, with signature, title, and notary commission details included.\"},{\"question\":\"How does this form affect workers’ compensation responsibilities?\",\"answer\":\"The form states the independent contractor will not be entitled to workers’ compensation benefits in the event of injury, and it includes a waiver for sole proprietors without employees. It also explains that if other hired/contracted individuals are not covered by workers’ compensation insurance, the policyholder may be charged premium.\"}]","Declaration of Independent Contractor Status Form | PDF",1789780923,{"code":4,"msg":75,"data":76},"ok",{"site_id":69,"language":68,"slug":77,"title":59,"keywords":78,"description":60,"schema_data":79,"social_meta":134,"head_meta":136,"extra_data":138,"updated_unix":139},"declaration-of-independent-contractor-status-form","",{"@graph":80,"@context":133},[81,96,116],{"@type":82,"itemListElement":83},"BreadcrumbList",[84,88,90,93],{"item":85,"name":86,"@type":87,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":89,"name":10,"@type":87,"position":66},"https://docshare.wps.com/template/",{"item":91,"name":36,"@type":87,"position":92},"https://docshare.wps.com/template/forms/",3,{"item":94,"name":59,"@type":87,"position":95},"https://docshare.wps.com/template/declaration-of-independent-contractor-status-form/301303/",4,{"url":94,"name":59,"@type":97,"image":98,"author":103,"headline":59,"publisher":105,"fileFormat":108,"inLanguage":68,"description":60,"dateModified":109,"datePublished":110,"encodingFormat":108,"isAccessibleForFree":111,"interactionStatistic":112},"DigitalDocument",{"url":99,"@type":100,"width":101,"height":102},"https://docshare.wps.com/thumbnails/declaration-of-independent-contractor-status-form/301303.png","ImageObject",442,249,{"name":57,"@type":104},"Person",{"url":85,"name":106,"@type":107},"DocShare","Organization","application/pdf","2026-09-24","2026-09-19",true,{"@type":113,"interactionType":114,"userInteractionCount":66},"InteractionCounter",{"@type":115},"ViewAction",{"@type":117,"mainEntity":118},"FAQPage",[119,125,129],{"name":120,"@type":121,"acceptedAnswer":122},"What does the independent contractor certify on this form?","Question",{"text":123,"@type":124},"The independent contractor certifies the individual is an independent contractor (not an employee) and that the business relationship meets specific criteria regarding control, standards, compensation structure, termination, training, tools/benefits, scheduling, and separate operations.","Answer",{"name":126,"@type":121,"acceptedAnswer":127},"When is the contractor certification completed and who must be present?",{"text":128,"@type":124},"The certification by the independent contractor must be completed in the presence of a Notary Public, with signature, title, and notary commission details included.",{"name":130,"@type":121,"acceptedAnswer":131},"How does this form affect workers’ compensation responsibilities?",{"text":132,"@type":124},"The form states the independent contractor will not be entitled to workers’ compensation benefits in the event of injury, and it includes a waiver for sole proprietors without employees. It also explains that if other hired/contracted individuals are not covered by workers’ compensation insurance, the policyholder may be charged premium.","https://schema.org",{"og:url":94,"og:type":135,"og:title":59,"og:site_name":106,"og:description":60},"article",{"robots":137,"canonical":94},"index,follow",{"doc_id":55,"site_id":69},1790235593]