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. ?23-901 (et.seq.), and specifically, A.R.S. ?23-961(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-- 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: ___________ Zip Code:
Signature: _________________________________________ Date: ________________
A copy of this waiver will be kept on file and will be available for audit purposes.
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