HomeMy WebLinkAboutPeter Werwath - Montana workmen's comp exemption certificateMONTANA DEPARTMENT OF LABOR & INDUSTRY
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Department of Labor & Industry
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THIS CERTIFICATE CERTIFIES THAT I
PETER C WERWATH
8825 BLUE SEA DRIVE
COLUMBIA, MD 21046
has sworn 1o the Deparlment of Labor and Industry that this person is:
' cngaged in an independently established trade. occupation. profession. or business; and' is flee from control or dilection by hiring age[ts over fhe perfcrmrance of the person's setvices, both under contra.cf and in fact,
when acting as an indcpendent contractor.
The certificate holder has provided the Department of Labor and Industry sufficient docurnentation to conclude the certificate holder
has an established business. In reliance on that evidence, the Department of Labor and Industry has granted this Independent
Contractor Exemption Certificate to the person named above.
The certificate holder has waived all rights and benefits under the Workers' Compensation Act of Montana and is not required to be
pcrsonally covered by workers' compensation insurance. The certificate holder has acknowledged the certi{icate holder is responsible
for all taxes related to work performed under the Certificate.
Any certificate holder, hirirrg agent, employer, or any other person who violates the indepcndent conh?cror provisions of Title 39.
Chapter 71 , MCA may be s"61rit to a $ iOOO fine and other pinalties provided by law. , ,
This Certificate is eftbctive for the following I occupalion(s) (list may continue onrnext page):
Effective: lll05l20l4 through 1110412016
-. END OF OCCUPATION LIST.-
This certificate only applies to the above named person for the listed occupation(s) and does not include any employees the person may hire or any other
subconffactors bired by the above named person. Montana law provides that this Ceftificate creates a conclusive presumption of this person's status as an
independent contractor.
ATTENT]ON HIRING AGENTS:
It is advisable to veriS that this is valid and effective. Please call (406) 444-7734 or visit our website at www.mtcontractor.com
Please notify the Department oflabor and Industry ofany changes to this Certificate.
(406) 444--1734 - (406) 444-3465 fax - (406) 4M-5549 (TTD) - PO Box 8011, Helena, MT 59604-8011
ICEC Refereuce No.: 125729IC (This is not a registration or license number.)
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