Employment Information
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For any of the questions below, you may add additional information on separate pages and include any documents that you feel are helpful:
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Provide the following information (Name, Type of work performed and worksite name and location) about each worker that you believe the business misclassified, including yourself if applicable:
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Provide the following information (worksite name and location, project, dates when work was performed, worksite supervisor, name of general contractor) about worksite where you believe the business misclassified workers:
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What led you believe that this business misclassified employees as independent contractors?
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Did the business have any other person who provided the workers directions or orders besides the workspace supervisor(s)?
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If so, please identify the(se) person(s) and worksite(s):
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Did the business supply the workers with tools, equipment and other supplies to do their work?
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If yes, what tools, equipment and supplies were provided by the business:
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What tools, if any, did the worker(s) supply?
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Did any of the workers have their own business?
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If yes, please explain and provide the business location
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Did any of the workers have their own liability insurance?
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If yes, when was it in effect? (Please provide a copy of the declaration page, if available)
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How were the workers paid? (Please check all that apply and explain in detail)
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Per job:
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Per hour:
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Per day:
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Piece work:
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Other:
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Explain in detail:
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Who paid the workers?
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Do you have wage records (such as paystubs, W-2 or 1099 forms) relating to any of the workers?
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Did any of the workers have a written agreement to perform work at any of the worksites?
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If yes, please attach the documents below (You can attach upto three documents):
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