2024-09-19_COI_GL_Auto_SPW_Crowthers-.pdf

PDF 2 MB Posted Nov 13, 2023

Attached to: Master Agreement AZ|CTR068585
Contract number: CTR068585
Issued by: Arizona

About this file

Written by GovTribe AI · Nov 4, 2025

This is a Certificate of Liability Insurance and associated policy documentation for Lonell Crowther, doing business as Crowther's Freshwater Trout, located in La Jara, Colorado. The insured is contracted with the State of Arizona, specifically the Arizona Game and Fish Department. The insurance is provided by Colorado Farm Bureau Insurance Co, with policy number 01-CL-000508779-14 END: 002, effective from September 19, 2023, to September 19, 2024. The producer is Salapich Agency LLC located in Walsenburg, Colorado. The certificate holder is the Arizona Game and Fish Department, 5000 W Carefree Highway, Phoenix, Arizona 85086.

The Commercial General Liability coverage includes limits of $1,000,000 per occurrence for bodily injury and property damage, with a $2,000,000 general aggregate limit. Commercial Automobile Liability coverage maintains a combined single limit of $1,000,000 per accident. Additional coverage includes Products-Completed Operations at an included limit. A policy change effective February 2, 2024, adds a CG2404 Waiver of Subrogation for the Arizona Game and Fish Department with a $50 additional premium. The total policy premium is $0.00. The contract identification is CTR068585, and a Sole Proprietor Waiver has been executed, confirming that Lonell Crowther is an independent contractor without employees and therefore waives entitlement to workers' compensation benefits from the State of Arizona.

View the file

Other files

File	Type	Posted
CTR068585_-_Amendment_31_day_extension__2_.pdf	PDF	Nov 13, 2023
CTR068585_YR3_Contract_Renewal_AZGFD_Signed.pdf	PDF	Nov 13, 2023
CTR068585_Contractor_Proposal_Crowthers_Freshwater_Trout.pdf	PDF	Nov 13, 2023
CROWTHERS_COI__1_.pdf	PDF	Nov 13, 2023
CTR068585_Contract_Extension_-_Determination_YR_2_s.pdf	PDF	Nov 13, 2023
2025-09-19_CROWTHER_COI.pdf	PDF	Nov 13, 2023
CTR068585_Contract_Documents_Crowthers.pdf	PDF	Nov 13, 2023
CTR068585_Pricing.pdf	PDF	Nov 13, 2023
Crowthers_Sole_Proprietor_Waiver.pdf	PDF	Nov 13, 2023

On GovTribe

Work with this file

Download the original file
Contacts named in this file
Similar government files
Ask GovTribe AI about this file

Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

�� !� "#$��%�&'��(�)**)+�,)-��.�/0�-1213�)+45� �6#$��7# 5�� 8%69�� !,)-��.�+):;<=>?=;;;@;ABBC=<DEFGHIE;;JEKFGFLM?ENOI;<=>?=;;;@;ABBC=<P�1��)Q+3�+Q* 02:��+1*0/��+4Q20/�1+/�*1�-�+R�1//2044 1R0+�.�1+/�*1�-�+R�1//2044��DDJD;?NGF??E>KNLSTFKHUME>KNLSTFKVWEOKFWTELMSFKESKNXS<ABCYEXWETLZEJA@?ME[MKM\E>NEA<<D;=CDJB ]M?FK̂FE?MKWNGJDBEMHM_WEWS_NGSFE]̂WSM\E>NEA<<DDE,)-��.�,02�)/Ìa6%��;Cb<CbJ;JPc!%�;Cb<CbJ;JDc#!��(d'��#��9!# 8#68�!"��#!�e%f6��#"$" 5�#886�99�97%g �#h%i��;J=;A=JDE j�k��lm�(�mm��n�o��;Jb;JbJ;JDEnp�q�rl��s��t��u�u��q�qplv��)**)+�,)-��.�/0�-1213�)+4al��uu�n�l��w��nx��r��t�xt��np��n�tq�y��lv��p��k�u��q��u��n�udMzz{|}E>~JD;DEL�{��E��EW��}��{�|E��EM�{��|�E~��E�|zEO{��EH��|��E�@;E�zz{�{�|��E��{�� %�#88"!"% #$�%6�6�!f6 �j6��"f��8f��a%6��%��6�"#$�j6%j�6!e�� GNE>TMG~FE %�#88"!"% #$�%6�6�!f6 �j6��"f��8f��a%6��%��6�"#$�5� �6#$�$"#h"$"!e�� GNE>TMG~FE�j6��"f��8f��a%6��%��6�"#$��6"��# 8�a"8�$"!e�� %�#88"!"% #$�%6�6�!f6 �j6��"f��8f��a%6��%��6�"#$�" $# 8��#6" �� GNE>TMG~FE %�#88"!"% #$�%6�6�!f6 �j6��"f��8f��a%6��%��6�"#$�#f!%�� GNE>TMG~FE %�#88"!"% #$�%6�6�!f6 �!6# 9#�!"% �j6��"f�d �;E!%!#$�9f6�7#65��w�!#��9�w�a��9d Ej%$"�e�j6��"f�d �;�;;�� ¡��¢�£�¤��¥�

�� !� "#$��%�&'��(�)**+,��-.�-/0)*) �.+�1).��23� �4#$��5# 3�� 6%47�� !1).��2�8)9�:;<=><:::?:@AAB<;CDEFGHD::I,+8+J-.�)�K:;<=><:::?:@AAB<;L-��)/80�8/* +,M�8-*+N��8O/,+N�-8N�*-�.�8P�-NN,+OO -P+8�2�-8N�*-�.�8P�-NN,+OO CCIC:D>QFE>>D=RQSTUERGVWD=RQSTUERXYDZREYUDSWTERDTRQ[T;@AB\D[YDUS]DI@?>WD̂WRW_D=QD@;;C:<BCIA Ẁ>ERaED>WRYQFICADWGWbYDYTbQFTED̀aYTW_D=QD@;;CC1).��2�1+,�)NM�c4%��:Bd;BdI:ILe!%e:Bd;BdI:ICe#!��(f'��#��7!# 6#46�!"��#!�g%h4��#"$" 3�#664�77�75%i �#j%k�:I<:@<IC l�m��no��oo��p�q��:Id:IdI:IC�pr�s�tn��u��s��v��w�w��s�srnx��# h#$"y�6��cc��!�%c�� 6%47�� ! z :#66"!"% #${�%��4�"#$�#h!%{l4��"h� z :!%!#$��l4��"h� z :|::� 0}+O+�N+�.-,-0�)8O~��-11.��- .+~�0)P+0}+,�J�0}�0}+��)**)8�1).��2��)8N�0�)8O~��)�+,-P+��),*�O��-8N�+8N),O+*+80O~�-8N�O/11.+*+80-.��),*�N+�.-,-0�)8�O�~��-82~��OO/+N�0)��),*�-�1-,0�0}+,+)�~��)*1.+0+�0}+�- )�+�8/* +,+N�1).��29��

�� !� "#$��%�&'��(�)*+,�,�-./01.2)1��3�4)56789:8666;6<==>87?@ABCD@66EFGHGIJKLMNO@6789:8666;6<==>87PQ��)04R�40+ .*5�4Q+./��4,0*./�Q4/�+Q�1�4S�Q//*.,, QS.4�3�Q4/�+Q�1�4S�Q//*.,,��??E?6:TBA::@9UTVWXAUCYZ@9UTVWXAU[\@]UA\X@VZWAU@WUT̂W7<=>_@̂\@XV̀@E<;:Z@aZUZb@9T@<77?68>?E= cZ:AUdA@:ZU\TBE?=@ZCZe\@\WeTBWA@cd\WZb@9T@<77??@2)1��3�2.*�)/5ffgh%�i6>j7>jE6EPi!%i6>j7>jE6E?i#!��(k'��#��l!# m#hm�!"��#!�n%oh��#"$" p�#mmh�ll�lq%r �#s%t��6E86<8E? u�v��wx��4)R.5��4)�.4R*3�Q22.Q*,�)4�R-.��)11)y�4S�.4/)*,.+.4R,z��4�)*+QR�)4�*.{0�*./�R)��)+21.R.�R-.��)*+�y�11� .�,-)y4�)4�R-.�,0221.+.4RQ1��)*+�/.�1Q*QR�)4��++./�QR.13��)11)y�4S�R-.�Q221��Q 1.�.4/)*,.+.4R|�4R.*1�4.��)*+, Q221��Q 1.��)}.*QS.�2Q*R,d:7E67@778<; ~��@9�� 9��@Z��b@��@:��b@9��@d��@e��b@9��@~�� e��)++.*��Q1�S.4.*Q1�1�Q �1�R3��)*+,9�E?6?@7E87> V��@T�@W��@T�@U��@T�@U��@Z��@T��@W�@̂�@�V��@T�@\��@8@7 Z��)++.*��Q1�Q0R)��)*+,�)++.*��Q1��41Q4/�+Q*�4.��)*+, �� ¡¢£¤�¥£¦ £§£̈�©�¡ª£

�� !"#$%&'�(%)*#+*�,�)*&#-..�)*"#$%)/"###0123##�� !"#$+-#��44*�)�(5#6�&7#+*�,�)*&"#$%)/"###0123# �89:��;<�� # =�5�)�#� (%�*#>'4?*�#@#AAB=-C$�D#>EFGH6AIJKLJAAAMANOOPJIQRSTUVRAAB =-C$�D#�WX>YH+HZZH�[$\HAB]AB]BABQ �-F=X>DK̂ _̂ àb̂RcàdRef̀gafRhijf̀aikgRK̂>XFHl#$>+E6HlLmTSLLRKnmopqSn XE[W-6$rHl#6H=6H+H>[X[$\H�-\H6XYH#=X6[+#XZZH�[Hlsgig̀a_RLtaut_tvw �WX>YH+xbbtiyRKsBQAQRoatzg̀ R̂{R|fù ŷavt̂iR{̂ R̀x̀t}̂iaRsadgRaibRctj~RUg�àvdgiv�R�MARabbtvt̂iJa_R�̀gdtfd� X'! ��*�#6*��*&*%!(!�,*#+��%(!'�*

�� !"�#$%&'!(!"$%&%#$)#%#*+�'&,-&.-&/,&/0*1#2&!(3�"2! !(*&�1$('!2&*1!&4�%#�+5&&4%!$2!&"!$3&#*&�$"!67%%+5�'&,-&.-&/,&/0 8��9:;<=9>?�@?<AB>?:��CCB>?D��9>ED�FGHI� 4JKL&/&MN&/O$#P!"&�6&*"$(26!"&�6&"#'1*2&�6&"!��P!"+$'$#(2*&�*1!"2&*�&72&QO$#P!"&�6&27)"�'$*#�(RSTB:�?9UV<:?W?9X�WVUBCB?:�B9:;<=9>?�Y<VABU?U�;9U?<�XT?�CVZZV[B9\ ��S��_��]̂ ��]�S��S��̀]S]��] ��S��_��]̂ ��]�S��a��] ��S��_��]̂ ��]�S��S��] ��S��_��]̂ ��]�S�̀�@�̂�]S�̀ �@�S�@��S��] ��S�� S�̀ ��_��]̂ ��]�S�̀�@�̂�]S�̀ �@�S�@��̀ ��S@b�� S�̀ ��]S��@��] ��S��_��]̂ ��]�S�]��]̀ ��S��S�_��] ��S��_��]̂ ��]�S��̀ ��̂ ��̀ �@S��]̂ ��S]�c��̀�@�̂�]S�̀ �S]�c@2�1!37%!(JdL&�N&4LefMgQfR&�e&�eKJghiJjhMgQfRk&lmnopqr�srtu�lqv�wnxy��uzrm{tuq{�9CV<W=XBV9�<?|;B<?U�XV�>VWYZ?X?�XTB:�@>T?U;Z?D�BC�9VX�:TV[9�=}VA?D�[BZZ�}?�:TV[9�B9�XT?�̀?>Z=<=XBV9:EST?�CVZZV[B9\�B:�=UU?U�XV��=<=\<=YT�~5&*eJgfNLe&�N&"hK�jf&�N&"L�M�Le�&$KJhgfj&�j�Lef&*M&7f�VC�2L�jhMg&#P&�&�Mg�hjhMgfk�?�[=BA?�=9��<B\TX�VC�<?>VA?<��=\=B9:X�XT?�Y?<:V9�:��V<�V<\=9B�=XBV9�:��:TV[9�B9�XT?�@>T?U;Z?�=}VA?�}?>=;:?�VC�Y=�W?9X:�[?�W=�?�;9U?<�XTB:��VA?<=\?��=<XE�@;>T�[=BA?<�}��;:�=YYZB?:�V9Z��XV�XT?�?�X?9X�XT=X�XT?�B9:;<?U�T=:�[=BA?U�BX:�<B\TX�VC�<?>VA?<��=\=B9:X�:;>T�Y?<:V9�:��V<�V<\=9B�=XBV9�:��Y<BV<�XV�ZV::E�STB:�?9UV<:?W?9X�=YYZB?:�V9Z��XV�XT?�Y?<:V9�:��V<�V<\=9B�=XBV9�:��:TV[9�B9�XT?�@>T?U;Z?�=}VA?E�

ARIZ@NA

DEPARTMENT OF ADMINISTRATiON

RiSK MANAGEMENT

SOLE PROPRIETOR WAIVER

IF YOU ARE CONTRACTING WTH A CORPORATION, LIMITED LIABILITY COMPANY

(INCLUDING SINGLE MEMBER LLC), PARTNERSHIP, OR SOLE PROPRIETORS 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. S 23-961(M), that provides that a Sole Proprietor may waive his/her rights to Workers' Compensation coverage and benefits.

I am a sole proprietor and I am doing business as Crowthe/s Freshwater Trout

I am performing work as an independent contractor for the State of Arizona Game and Fish Dept , for to workers' compensation benefrts workers' compensation purposes, and therefore, I am not entitled from the State of Arizona, I understand that if I have any employees working for me, I must maintain workers' compensation insurance on them.

Once top portion Agency representative for processin g

Game and Fish Dept

LonellCrowther

ZIP Code: 81140

Telephone Number: G19)2744060

Name of Sole Proprietor:

Street Address / p. O. Box: 18796 State Hwy 285

LaJaraCity:

Signature

State: co

Fish Dept

CTRO685B5

Date:

Agency * 724 f,State Agency: Arizona Game

Contract I dentifi cation :

Signature of Agency Contract Ad mi nistrator:

An authorized Management agency to be maintained in their records.

will sign your completed form and return it to the

Signature of Risk Management Authorized Signer Date

Revised 06-29-2021 w,Wo

11/29/2023

Revised 04-05-2019

SOLE PROPRIETOR WAIVER

NOTE: THIS FORM APPLIES ONLY TO STATE OF ARIZONA AGENCIES, BOARDS,

COMMISSIONS, AND UNIVERSITIES UTILIZING SOLE PROPRIETORS WITH NO EMPLOYEES.

IF YOU ARE CONTRACTING WITH A CORPORATION, LIMITED LIABILITY COMPANY

(INCLUDING SINGLE MEMBER LLC), PARTNERSHIP, OR SOLE PROPRIETORS 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(M), that provides that a Sole Proprietor may waive his/her rights to Workers' Compensation coverage and benefits.

I am a sole proprietor and I am doing business as Name Of Sole Proprietor's Business. I am performing work as an independent contractor for the State of Arizona, Enter State Agency, Department And/Or Division, for workers' compensation purposes, and therefore, I am not entitled to workers' compensation benefits from the State of Arizona, Enter State Agency, Department And/Or Division. I understand that if I have any employees working for me, I must maintain workers' compensation insurance on them.

Name of Sole Proprietor: Lonell Crowther

Name of Sole Proprietor’s Business: Crowther's Freshwater Trout

Street Address/P.O. Box: 18796 State Highway 285

City: LaJara State: Colorado ZIP Code: 81140

Signature of Sole Proprietor: Signature on file Date:

State Agency: Game & Fish/Dept

Email Address: dbailloux@azgfd.gov

Agency Contract Administrator: Donna Bailloux Date: 11/29/2023

Contract Identification: CTR068585

Karina Charley 16910 11/30/2023

Signature of Risk Management Authorized Signer / Request # Date http://www.azleg.state.az.us/FormatDocument.asp?inDoc=/ars/23/00901.01.htm&Title=23&DocType=ARS http://www.azleg.state.az.us/FormatDocument.asp?inDoc=/ars/23/00961.htm&Title=23&DocType=ARS

2024-09-19 COI Crowthers-.pdf

2024-09-19 COI - SPW Crowthers-.pdf

2024-09-19 COI Crowthers-.pdf

Lonell CG2144

Crowthers Sole Proprietor Waiver to Risk

Sole Proprietor Waiver - 16910 Crowthers SPO appvd

File details come from the government source that posted it. Updated Nov 4, 2025.