WORKERS’ COMPENSATION WAIVER FORM
WORKERS¡¯ COMPENSATION WAIVER FORM
The following is a written waiver under the compulsory Workers¡¯ Compensation laws of the State of
Arizona, A.R.S. ¡ì23-901 (et.seq.), and specifically, A.R.S. ¡ì23-961(1), that provides that a Sole
Proprietor may waive his/her rights to Workers¡¯ Compensation coverage and benefits.
I am a sole proprietor/independent contractor and I am doing business as:
(Please Print¡ª Company Name or Name of Sole Proprietor/Independent Contractor)
I am performing work as a company/sole proprietor/independent contractor for Agro Land & Cattle Co.,
Inc.
Therefore, neither myself not any of my staff are employees of Agro Land & Cattle Co., Inc. or any
additional insureds as listed;
Therefore, for workers¡¯ compensation purposes, neither I nor any of my staff are entitled to workers¡¯
compensation benefits from Agro Land & Cattle Co., Inc.
I understand that if I have any employees working for me, I must maintain workers¡¯ compensation
insurance on them.
Name of Sole Proprietor:
____________________________________
Social Security Number:
_________________________________________
Street Addres/P.O. Box:
_____________________________________
City: _________________________ State:
___________
Signature: _________________________________________ Date:
Zip Code:
________________
A copy of this waiver will be kept on file and will be available for audit purposes.
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