SOLE PROPRIETOR WAIVER/SINGLE MEMBER LLC WAIVER

[Pages:3]Doctype: Waiver SOLE PROPRIETOR WAIVER/SINGLE MEMBER LLC WAIVER

NOTE:

THIS FORM APPLIES ONLY TO SCF ARIZONA POLICYHOLDERS UTILIZING SOLE PROPRIETORS OR SINGLE MEMBER LLC WITH NO EMPLOYEES. IF YOU ARE CONTRACTING WITH A CORPORATION, PARTNERSHIP, LIMITED LIABILITY COMPANY (TREATED AS A CORPORATION OR PARTNERSHIP), OR A SOLE PROPRIETOR/SINGLE MEMBER LLC WITH EMPLOYEES, THIS FORM DOES NOT APPLY.

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 (O), that provides that a Sole Proprietor may waive his/her rights to Workers' Compensation coverage and benefits.

I am a Sole Proprietor or a Single Member LLC and I am doing business as:

I am performing work as a Sole Proprietor/Single Member LLC for (Name of Sole Proprietor/Single Member LLC Business

(Name of Policyholders Business

I am not the employee of

(Name of Policyholders Business

for workers' compensation purposes, and therefore, I am not entitled to workers compensation benefits from

(Name of Policyholders Business

I understand that if I have any employees working for me, I

must maintain workers' compensation insurance on them.

PLEASE TYPE OR PRINT IN BLUE OR BLACK INK

Name of Sole Proprietor/Single Member:

Social Security Number:

Street Address/P.O. Box:

City:

State:

Zip Code:

Signature of Sole Proprietor/Single Member:

Date:

Policyholder Business Name:

SCFAZ Policy #:

Street Address/P.O. Box:

City:

State:

Zip Code:

Signature of Policyholder:

(Owner, Partner or Corporate Officer)

Print Name of above Signature:

Date:

The signatures of both parties are required on the completed form. The Business Questionnaire and other supporting documents must be submitted to the SCF Arizona. An authorized SCF Arizona Representative will review and if approved, countersign and return to you. Waiver is not effective unless and until signed by a SCF Arizona Representative. The validated Waiver must be kept in your records and made available to our auditors upon request

Signature of SCF Arizona Representative

61-511 Rev.11/06

Review Date

Waiver Effective Date

SCF ARIZONA BUSINESS QUESTIONNAIRE

Doctype: Waiver

PLEASE CHECK APPROPRIATE BOX Application

Independent Contractor

Sole Proprietor/Single Member LLC

Company Name: (Check and answer questions)

1. Do you have a Federal Tax I.D. Number? If yes, provide Number

Yes

No

2. Have you filed Schedule C, Form 1040 on prior Tax Returns? If yes, provide copy of last year's Schedule C, Form 1040.

Yes

No

3. Have you paid self employment Tax previously? If yes, provide copy of FICA, Schedule SE 1040.

Yes

No

4. Do you invoice bill your services to customers? If yes, provide copy of sample invoice.

Yes

No

5. Do you carry business liability insurance? If yes, provide copy of Policy or Certificate of Insurance.

Yes

No

6. Are you licensed by the Registrar of Contractors? If yes, provide copy of License.

Yes

No

7. Do you have a Business Tax License? If yes, provide copy of License.

Yes

No

8. Do you have a separate business bank account in the Company Name? If yes, provide a voided Business check.

Yes

No

9. Do you have an investment in tools, equipment or inventory other

Yes

than hand tools?

If yes, briefly list type of tools, inventory or equipment maintained:

10. Do you maintain a business location other than your residence? If yes, provide address:

Yes

No

11. Are you paid by the hour or by the job?

12. Do you advertise in any publication (including the phone book? If yes, please identify publication name: If no, how do you get new business?

13. Who schedules the work to be done for the customer?

Yourself?

Yes

No

Company that hired your services?

14. Who does the customer call if dissatisfied with your work? Yourself

Company that hired your services?

15. Do you have a business accounting service to handle payroll, DES Reports, Business Taxes, Etc.? If yes, provide name, address, and phone number of Accountant:

Yes

No

16. List names of companies you are working for or are seeking work from. Identify those that will require a Certificate of Workers' Compensation Insurance:

17. Have you ever worked for the company requiring Certificates, either as a subcontractor or an employee?

(Signature of Applicant, Independent Contractor or Sole Proprietor/Single Member LLC)

Yes No (Date)

61-080.4 rev 11/06

Doctype: Waiver

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