Designation of Status as an Independent Contractor:
Click here to fill out the form securely online or
click here to download the form in PDF format or in Excel format. Revised 2/06
The purpose of this DWC-11-IC form is to clarify the relationship between a contractor and the business hiring the contractor. Submitting this form means that the contractor is not an employee of the hiring business for workers' compensation purposes. The contractor is responsible for his own workers' compensation insurance coverage. The hiring business is not responsible to provide workers' compensation coverage for the independent contractor.

Notice of Withdrawal of Designation of Independent Contractor:
Click here to fill out the form securely online or
Clcik here to download the form in PFD format or in Excel format. Revised 2/06
The purpose of this DWC-11-ICR form is to end the relationship between a contractor and the hiring business. Submitting this form means that the contractor is no longer independent of the hiring business named on this form. If the contractor continues to work for this business, the business would be responsible to provide workers' compensation coverage for the contractor.

To download the forms in pdf form, you must have Adobe Acrobat Reader Version 4 or higher. You must have Adobe Reader 6.0 or greater to fill out the pdf form.

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For independent contractor information, contact (401) 462-8100 option 5.