DEPARTMENT OF LABOR AND REGULATION

 

DIVISION OF INSURANCE

 

 

 

 

AFFIDAVIT OF EXEMPT STATUS

 

 

Chapter 47:03:10

 

APPENDIX A

 

SEE: § 47:03:10:01

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

          Source: 41 SDR 219, effective July 1, 2015.

 

 

 

APPENDIX A

 

 

STATE OF SOUTH DAKOTA )

 

                                                     ) SS                                       AFFIDAVIT OF EXEMPT STATUS

 

COUNTY OF ______________

 

I state under oath as follows:

 

          1.  I, ______________________, operating as_____________________________________,       (Independent Contractor)                               (Independent Contractor's Business Name)

 

               have agreed to provide services for ____________________ during calendar year _____.

                                                                           (General Contractor)                                                  (Year)

 

         2.  I have read, signed, and attached the Exempt Status Fact Sheet and understand that an Independent Contractor is one who engages to perform certain services for another, according to his own manner and method, free from control and direction of the contractor in all matters connected with the performance of the service, except as to the result or product of the work.

 

         3.  I understand that based upon the representations in this Affidavit of Exempt Status that I have signed, I am requesting that the Contractor identified above consider my business to be that of an independent contractor; that I am not an employee under the Workers' Compensation Act and the policy issued by ___________________________________.

                                                                                           General Contractor's Insurance Carrier

 

         4.  I am an independent contractor, not an employee of the contractor, and I do not want workers' compensation insurance.

 

         5.  I am not an employer for the purposes of the Workers' Compensation Act.

 

         6.  I have read, signed, and attached the Exempt Status Fact Sheet describing what an Independent Contractor is and the information provided is not the result of force, threats, coercion, compulsion, or duress.

 

         7.  I understand that the execution of this affidavit shall establish a rebuttable presumption that I am not an employee for purposes of the Workers' Compensation Act.

 

         8.  I understand that by signing this affidavit I will not be eligible for compensation under the South Dakota Workers' Compensation Law.

 

         9.  I understand the execution of this affidavit does not affect the rights or coverage of any employee of the individual executing the affidavit.

 

         10. I understand that soliciting or providing false information on this affidavit with actual knowledge is a Class 2 misdemeanor.

 

_______________________________                         ___________

Independent Contractor Signature                                Date

 

_______________________________                         _______________________________

Independent Contractor Name                                     Title

 

Subscribed and sworn to before me this ________ day of _____________, 20 _____.

 

________________________________

Notary Public- South Dakota

 

               (Seal)

 

My commission expires:_____________

 

________________________________                       ___________

General Contractor Signature                                        Date

 

________________________________                       _______________________________

General Contractor Name                                             Title

 

Subscribed and sworn to before me this _________ day of _____________, 20 _____.

 

_________________________________

Notary Public-South Dakota

 

               (Seal)

 

My commission expires:_____________.