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Umbrella
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Self Employed (CIS) Assessment

Before filling out this form, please read our specialised services contract here

This assessment is required to enable us to assess your self-employment status and determine that you are not under Supervision, Direction and Control. Please answer all of the following questions in respect to your services, whether by reference to us, the agency or the client.

Name

Mobile

Phone

Email

Job Title

Professional Qualifications Held

Please describe the role to be undertaken for the assignment:

Length of Time in Role

Please attach Certificates/CV If you find that you have exceeded the upload file size limit of 16MB please use WeTransferFile InputNo Files ChosenAccepted file types: jpg, jpeg, jpe, mka, 7z, xla, xls, xlt, xlw. Max. file size: 16 MB

How many assignments have you completed in the last 12 months using your UTR No?

Would you be entitled to Holiday pay, sick pay, a company pension scheme or other such benefits? Would you be entitled to Holiday pay, sick pay, a company pension scheme or other such benefits? Yes No

Are you responsible to complete, either yourself or via an accountant, an annual self-assessment tax return? Are you responsible to complete, either yourself or via an accountant, an annual self-assessment tax return? Yes No

Are you responsible for all your own expenses in relation to travelling to/from site and/or overnight accommodation? Are you responsible for all your own expenses in relation to travelling to/from site and/or overnight accommodation? Yes No

Are you under any obligation to accept or receive future assignments from the Client or the Agency? Are you under any obligation to accept or receive future assignments from the Client or the Agency? Yes No

Do you understand that a suitably qualified alternative contractor can be supplied as a substitute to complete a task that you Do you understand that a suitably qualified alternative contractor can be supplied as a substitute to complete a task that you Yes No

Do you provide your own tools, equipment and/or PPE to carry out your assignments?* Do you provide your own tools, equipment and/or PPE to carry out your assignments?* Yes No

Do you have the freedom to contract on more than one assignment at any one time and choose the hours you work taking into acc Do you have the freedom to contract on more than one assignment at any one time and choose the hours you work taking into acc Yes No

Once given basic instructions of what to do for your day, will anyone else advise you how to complete these tasks? Once given basic instructions of what to do for your day, will anyone else advise you how to complete these tasks? Yes No

Acknowledgement Acknowledgement “I acknowledge that the responses I have provided in this questionnaire are a true and accurate description. The responses I have given apply to terms and conditions of my engagement with All Sourcing.”

Do you receive training with the exception of H&S training from anyone you currently provide services to?** Do you receive training with the exception of H&S training from anyone you currently provide services to?** Yes No

Will you be under constant supervision by anyone whilst undertaking your role? Will you be under constant supervision by anyone whilst undertaking your role? Yes No

Date Date

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