Butner, NC · Granville County
Independent Contractor Checklist
This checklist records contractor information and answers questions used to assess work relationships when a contractor has not provided proof of workers’ compensation insurance.
What this form is
The checklist is for each independent contractor retained by a public entity who has not provided a certificate of workers’ compensation insurance. It asks for the contractor’s name, work and business type, contract duration, employee count, and yes-or-no answers about the contractor’s work arrangements. The signer also provides a signature and date.
Who needs it
A person or business doing work as an independent contractor completes the checklist when they have not provided proof of workers’ compensation insurance.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This document is signed without a notary; the person or business doing the work signs and dates it, and no notarized attachment or sworn step is listed.
How to submit this form
- 1
Download The Checklist
Download the Independent Contractor Checklist PDF.
- 2
Complete The Checklist
Enter contractor and work details, then answer the yes-or-no questions.
- 3
Sign And Date
The person or business doing the work signs and dates the checklist.
- 4
Submit To The City
Submit it to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- What is the Independent Contractor Checklist for?
- It records contractor details and answers about the work relationship when a contractor has not provided a certificate of workers’ compensation insurance.
- What information does the checklist ask for?
- It asks for the contractor’s name, work and business type, contract duration, employee count, and answers about the contractor’s work arrangements.
- Do I need a notary for the Independent Contractor Checklist?
- No. The person or business doing the work signs and dates the checklist; it lists no notarized attachment or sworn step.
- How do I submit the Independent Contractor Checklist?
- Submit it to the city department named on the form; check the city website for current contact details.
Need something notarized?
This Independent Contractor Checklist doesn’t need a notary — but if you have another Butner form that does, a commissioned online notary can help.