• Complete the Independent Contractor Checklist (Part 1a). • Ask the potential contractor to complete Checklist (Part 1b) and Substitute form W-9.Sample Independent Contractor Agreement. The parties are signing this Agreement as of the date stated in the introductory clause. Include a copy of any contract and details of your relationship. If you have any other questions call the Liability and Determination Section at 518-457-2635. Jurisdiction and venue for any dispute arising out of this Agreement shall exclusively rest in the Pima County, Arizona. 33. An independent contract agreement helps to lay out work schedules, payment terms, and other essential details. Mercy Care serves Medicaid members in Arizona. Mercy Care Advantage (HMO SNP) serves members eligible for both Medicare and Medicaid.