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Section 1: TO BE COMPLETED BY INDEPENDENT CONTRACTOR. Name: Doing Business as (DBA):. 1.By signing this statement, I certify the above is a true and accurate statement of my status as an independent contractor. Signed: Date: (Independent Contractor). For workers' compensation purposes, we are required to maintain verification regarding workers' compensation coverage for all of our independent contractors. Contractor shall submit an itemized statement of Contractor's expenses. Client shall pay Contractor within 30 days after receipt of each statement. Form, Use this form to -. Find Form W9, Form 1099 and instructions on filing electronically for independent contractors. (Attach completed worksheet to Independent Contractor Agreement).