APPROVED 01.17.2021 - 01.17.2022.pdf

05/10/2021

Bowman & Associates Ins Agency 16042 N. 32nd St.

Phoenix AZ 85032

Lil Martin

(602) 482-3300 (602) 482-7525 lilm@bowmaninsurance.com

ROBERT THOMAS HELMER

dba: BILLBOARD VALUATION CONSULTANT 4409 E Friess Dr Phoenix AZ 85032

Auto Owners Ins Company 18988 Owners Insurance Company 32700

2021/22

A blanket Additional insured Waiver of Subrogation Y 4569408 01/17/2021 01/17/2022

2,000,000 100,000 5,000 2,000,000 4,000,000 4,000,000

B blkt WOS Blkt AI

Y 44839181-01 01/17/2021 01/17/2022

1,000,000

Certificate holder is addltional insured on Blanket Additional Insured per written contract. Primary non-contributory wording, Waiver of Subrogation applies Subject to policy terms and conditions.

ADOT

1324 N 22nd Avenue MD 128A

Phoenix AZ 85009

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INSURER(S) AFFORDING COVERAGE

INSURER F :

INSURER E :

INSURER D :

INSURER C :

INSURER B :

INSURER A :

NAIC #

NAME:

CONTACT

(A/C, No):

FAX

E-MAIL

ADDRESS:

PRODUCER

(A/C, No, Ext):

PHONE

INSURED

REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.

If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED

REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

OTHER:

(Per accident)

(Ea accident)

N / A

SUBR

WVD

ADDL

INSD

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

$PROPERTY DAMAGE

BODILY INJURY (Per accident)

BODILY INJURY (Per person)

COMBINED SINGLE LIMIT

AUTOS ONLY

AUTOSAUTOS ONLY

NON-OWNED

SCHEDULEDOWNED

ANY AUTO

AUTOMOBILE LIABILITY

Y / N

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH)

DESCRIPTION OF OPERATIONS below If yes, describe under

ANY PROPRIETOR/PARTNER/EXECUTIVE

E.L. DISEASE - POLICY LIMIT

E.L. DISEASE - EA EMPLOYEE

E.L. EACH ACCIDENT

ER

OTH-

STATUTE

PER

LIMITS(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

POLICY NUMBERTYPE OF INSURANCELTR

INSR

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

EXCESS LIAB

UMBRELLA LIAB $EACH OCCURRENCE

$AGGREGATE

OCCUR

CLAIMS-MADE

DED RETENTION $

$PRODUCTS - COMP/OP AGG

$GENERAL AGGREGATE

$PERSONAL & ADV INJURY

$MED EXP (Any one person)

$EACH OCCURRENCE

DAMAGE TO RENTED

$PREMISES (Ea occurrence)

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY

PRO-

JECT LOC

CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)

CANCELLATION

AUTHORIZED REPRESENTATIVE

ACORD 25 (2016/03)

© 1988-2015 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

DocuSign Envelope ID: 4099E27B-B4B9-41B2-897B-A60376A0ED47

ACCEPTED

ADOT Risk Management

COMMERCIAL GENERAL LIABILITY

CG 20 38 0413

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED - OWNERS, LESSEES OR

CONTRACTORS - AUTOMATIC STATUS FOR OTHER

PARTIES WHEN REQUIRED IN WRITTEN

CONSTRUCTION AGREEMENT

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

A. Section II - Who is An Insured is amended to include as an additional insured:

1. Any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy: and

2. Any other person or organization you are required to add as an additional insured under the contract or agreement described in Paragraph 1. above.

Such person(s) or organization(s) is an additional Insured only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by:

a. Your acts or omissions; or

b. The acts or omissions of those acting on your behalf;

in the performance of your ongoing operations for the additional insured.

However, the insurance afforded to such additional insured described above:

a. Only applies to the extent permitted by law;

and

b. Will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

A person's or organization's status as an additional insured under this endorsement ends when your operations for the person or organization described in Paragraph 1. above are completed.

B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply:

This insurance does not apply to:

1. "Bodily Injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including:

a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or

b. Supervisory, inspection, engineering activities.

architectural or

This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of, or the failure to render, any professional architectural, engineering or surveying services.

2. "Bodily injury" or "property damage" occurring after:

a. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or

CG 20 38 0413 © Insurance Services Office, Inc., 2012 Page 1 of 2

b. That portion of "your work" out of which the 2. Available under the applicable Limits of Injury or damage arises has been put to Its Insurance shown In the Declarations;

intended use by any person or organization whichever Is less other than another contractor or , * subcontractor engaged In performing This endorsement shall not Increase the operations for a principal as a part of the applicable Limits of Insurance shown In the same project. Declarations.

C. With respect to the Insurance afforded to these additional Insureds, the following Is added to Section III - Limits Of Insurance:

The most we will pay on behalf of the additional Insured Is the amount of Insurance:

1. Required by the contract or agreement described In Paragraph A.1 or

Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 38 0413

COMMERCIAL GENERAL LIABILITY

CG 20 01 04 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

PRIMARY AND NONCONTRIBUTORY -

OTHER INSURANCE CONDITION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

The following is added to the Other Insurance Condition and supersedes any provision to the contrary:

Primary And Noncontributory Insurance

This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that:

(1) The additional insured is a Named Insured under such other insurance; and

(2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured.

CG 20 01 0413 Insurance Services Office, Inc., 2012 Page 1 of 1

Certificate Number:

This Certificate forms a part of Master Policy Number:

Renewal of Master Policy Number :

NOTICE: THIS INSURANCE IS WRITTEN ON A CLAIMS MADE AND REPORTED BASIS AND ONLY APPLIES TO CLAIMS FIRST MADE AGAINST THE CERTIFICATE HOLDER DURING THE CERTIFICATE PERIOD. NO COVERAGE EXISTS FOR CLAIMS FIRST MADE AGAINST THE CERTIFICATE HOLDER AFTER THE END OF THE CERTIFICATE PERIOD UNLESS, AND TO THE EXTENT, A BASIC OR EXTENDED REPORTING PERIOD APPLIES.

NOTICE: DEFENSE EXPENSES ARE INCLUDED WITHIN AND REDUCE THE APPLICABLE LIMIT OF LIABILITY

STATED IN THE CERTIFICATE. PLEASE READ THE ENTIRE POLICY CAREFULLY.

1. Name and Address of Certificate Holder:

AZ 85032

2. Certificate Period: Effective Date: to Expiration Date: 1/24/2022 12:01 a.m. Standard Time at the Address of the Certificate Holder shown in item 1. above

2a. Retroactive Date: 3/7/2017 12:01 a.m. Standard Time at the Address of the Certificate Holder shown in item 1. above

3. Limit of Liability: 2,000,000$ each claim 2,000,000$

4. Deductible: 2,500$ each claim

5. Professional Covered Services insured by this policy are: REAL ESTATE APPRAISAL SERVICES

6. Advance Certificate Holder Premium: Surplus Lines Tax 33.33 Stamping Fee 2.22

Risk Purchasing Group Fee 40.00 Forms and Endorsements:

Total: $1,146.55

Agency Name and Address: Norman-Spencer Agency, LLC

County: Maricopa

Date: 1/29/2021

Pursuant to Arizona Revised Statutes Section 20-401.1, Sub-Section B, Paragraph 1, this policy is issued by an insurer that does not possess a certificate of authority from the Director of the Arizona Department of Insurance and Financial Institutions. If the insurer that issued this policy becomes insolvent, insureds or claimants will not be eligible for insurance guaranty fund protection pursuant to Arizona Revised Statutes Title 20

8075 Washington Village Drive

See Attached Forms Schedule

Countersignature (in states where applicable)

035908521-01

Authorized Representative OR

IT IS HEREBY UNDERSTOOD AND AGREED THAT THE CERTIFICATE HOLDER AGREES TO ALL TERMS AND CONDITIONS AS SET

FORTH IN THE ATTACHED MASTER POLICY.

aggregate limit

Dayton, OH 45458

(A Delaware Corporation)

AIG SPECIALTY INSURANCE COMPANY

Administrative Offices - 175 Water Street, 18th Floor, New York, NY 10038

1/24/2021

$268.00

$1,071.00

7. Minimum Earned Premium: 25% or

026244437-00

035908521-00

Phoenix

THE AMERICAN ACADEMY OF STATE CERTIFIED APPRAISERS

Helmer & Associates 4409 E. Friess Drive

NORMAN-SPENCER REAL ESTATE RISK PURCHASING GROUP INC dba

CERTIFICATE DECLARATIONS

Robert T. Helmer d/b/a

PRG 4110 5/20

Certificate Holder: Robert T. Helmer d/b/a Helmer & Associates

Certificate Number: 026244437-00 Effective Date: 01/24/21

Form Number Edition Date Title

PRG 4108 05/20 Real Estate Appraisers Professional Liability Coverage Form PRG 2078 08/19 Addendum to the Declarations - Signature Page PRG 3935 02/16 Premises Liability Coverage Amendatory Endorsement

PRG 4026 09/19

PRG 4027 09/19 Real Estate Appraisers Enhancement Endorsement 89644 06/13 Economic Sanctions Endorsement 91222 09/16 Policyholder Notice 118477 03/15 Policyholder Notice - Taxes, Assessments and/or Surcharges 119914 10/16

PRG 4040 11/19

PRG 4109 05/20

Access or Disclosure of Confidential or Personal Information Exclusion Endorsement

FORMS SCHEDULE

Recording and Distribution of Material or Information In Violation of Law Exclusion Endorsement Commercial Appraiser Amendatory Endorsement - Premium Audit Real Estate Appraisers - Master Policy Declarations - AIG Specialty

PRG 4110 5/20

PRG 2078 (10-2020)

ADDENDUM TO THE DECLARATIONS

By signing below, the President and the Secretary of the Insurer agree on behalf of the Insurer to all the terms of this Policy.

Michael Price Tanya Kent

PRESIDENT SECRETARY

This policy shall not be valid unless signed at the time of issuance by an authorized representative of the Insurer, either below or on the Declarations page of the policy.

Thomas McGrath

AUTHORIZED REPRESENTATIVE

PRG 3935 (2/16) ©All rights reserved. Page 1 of 4

PREMISES LIABILITY COVERAGE AMENDATORY ENDORSEMENT

This endorsement modifies insurance provided by the policy:

REAL ESTATE APPRAISERS PROFESSIONAL LIABILITY COVERAGE FORM – MASTER POLICY

SCHEDULE

$100,000 Each Premises Claim Limit $100,000 Annual Aggregate Limit $ 1,000 Each Premises Deductible

I. Section I. INSURING AGREEMENT is amended by including the following additional coverage:

Premises Liability

A. The Company shall also pay amounts up to the Each Premises Claim Limit shown in the Schedule above that the Certificate Holder is legally obligated to pay as damages and/or defense expenses because of a claim made against the Certificate Holder by reason of an Certificate Holder’s negligent act committed by an Certificate Holder or by another for whom the Certificate Holder is legally liable, to which this insurance applies. For this coverage to apply, all of the following conditions must be satisfied:

(1) The negligent act(s) must have commenced to occur on or after the retroactive date shown in Item 6. of the Declarations and before the end of the policy period;

(2) The claim must be first made against the Certificate Holder during the policy period or the extent applicable, the Automatic or Optional Extended Reporting Period;

(3) A Certificate Holder must report the claim to the Company, in writing, during the policy period, or to the extent applicable, the Automatic or Optional Extended Reporting Period;

and

(4) Prior to the effective date of the policy, none of the Named Certificate Holder’s officers, principals, partners, or other management or supervisory personnel had knowledge of an actual or alleged negligent act or circumstance that reasonably could give rise to a claim under this policy. If such officer, principal, partner or other supervisory personnel knew, prior to the effective date of this policy, of the negligent act or circumstance that reasonably could give rise to a claim under this policy, then any continuation, change or resumption of such negligent act or circumstance during or after the policy period will be deemed to have been known prior to the policy period.

B. The Company has the right and duty, at the Company’s expense, to defend and to appoint counsel for any claim brought against any Certificate Holder for a covered negligent act to which this insurance applies, even if the claim is groundless, false or fraudulent. However, the Company will have no duty to defend the Certificate Holder against any claim to which this insurance does not apply. The Company’s duty to defend any claim ends after the applicable Limit of Liability has been exhausted by payment of defense expenses or damages or both.

DEFENSE EXPENSES AND DAMAGES ARE SUBJECT TO AND INCLUDED WITHIN THE LIMITS OF

LIABILITY UNDER THIS POLICY AND WILL NOT INCREASE THE COMPANY’S LIMITS OF LIABILITY AS

STATED IN THE DECLARATIONS.

PRG 3935 (2/16) ©All rights reserved. Page 2 of 4

II. For the purpose of this Endorsement only, Paragraph C. of Section II. DEFINITIONS is amended to include the following:

Any person(s) or organization that referred customers or business to Certificate Holder for Professional Covered Services, but only where:

a. Such person(s) or organization is named in a claim that arises out of the Certificate Holder’s negligent act(s) covered under this policy;

b. Such person(s) or organization did not commit any of the aforementioned negligent act(s) giving rise to such claim; and

c. The claim alleges such person(s) or organization negligently referred business to the Certificate Holder for Professional Covered Services.

III. For the purpose of this Endorsement only, Paragraph E. of Section II. DEFINITIONS is deleted in its entirety and replaced with the following:

E. Claim(s) means a written demand for money that is based upon an actual or alleged negligent act of an Certificate Holder.

IV. For the purpose of this Endorsement only, the following definition is added to Section II.

DEFINITIONS:

Negligent act(s) means an act which results in bodily injury or property damage during the performance of Professional Covered Services, but only:

1. while the Certificate Holder is present on the premises providing Professional Covered Services; and

2. where the premises being appraised are not owned, rented, leased or controlled by the Certificate Holder.

IV. For the purpose of this Endorsement only, Paragraphs N. and O. of Section III. EXCLUSIONS are deleted in their entirety and replaced with the following:

N. for Bodily Injury. However, this exclusion does not apply to a claim for Bodily Injury arising out of the Certificate Holder’s actions or failure to act:

1. while the Certificate Holder is present on the premises providing Professional Covered Services; and

2. where the premises being appraised are not owned, rented, leased or controlled by the Certificate Holder;

O. for Property Damage. However this exclusion does not apply to:

1. Property damage To Lockbox Coverage as outlined in Paragraph C. in Section I. of this policy; and

2. Any claim for property damage arising out of the Certificate Holder’s actions or failure to act:

a. while the Certificate Holder is present on the premises providing Professional Covered Services; and

b. where the premises being appraised are not owned, rented, leased or controlled by the Certificate Holder;

PRG 3935 (2/16) ©All rights reserved. Page 3 of 4

V. For the purpose of this Endorsement only, the following Paragraphs are added to Paragraph G.

Limits of Liability and Deductibles of Section V. CONDITIONS:

Subject to the Aggregate Limit stated in Item 3. of the Certificate Declarations, the Annual Aggregate Limit shown in the Schedule above is the most the Company shall pay for damages and/or defense expenses for all covered claims arising from a negligent act(s) under this certificate.

Subject to the Annual Aggregate Limits shown in the Schedule above, the Each Premises Claim Limit shown in the Schedule above is the most the Company shall pay for damages and/or defense expenses for each covered claim arising from a negligent act(s) under this certificate. Once the Each Premises Claim Limit is exhausted, the Company shall have no further obligation under this certificate with respect to such claim.

All claims arising from a negligent act or negligent acts that are logically or causally connected by any common fact, circumstance, situation, transaction, event, advice or decision will be considered a single claim and shall be deemed to have been made when the first of such claims is made against the Certificate Holder.

VI. For the purpose of this Endorsement only, the following Deductible provision shall supersede all other provisions of the policy related to deductibles:

Premises Liability Deductible

The Named Certificate Holder shall be responsible for the Premises Liability Deductible amount shown in the Schedule above. Defense expenses the Company incurs in investigating and defending claims are included in the deductible. The deductible applies to each claim and the Named Certificate Holder may not insure against it. All claims arising from a single negligent act or continuous, repeated, or related negligent acts shall be subject to one deductible.

VII. For the purpose of this Endorsement only, Paragraphs B.(2) and I. of Section V. CONDITIONS are deleted in their entirety and replaced with the following:

B.(2) If the Named Certificate Holder becomes aware of any circumstance during the Certificate Period of a negligent act which may result in a claim against any Certificate Holder, the Named Certificate Holder will notify the Company in writing as soon as practical at the following address:

Lexington Insurance Company/Member of AIG Care of OSS P.O. Box 25947 Shawnee Mission, KS 66225

To the extent possible, notice should include:

a. How, when, and where the negligent act took place;

b. The names and addresses of any injured persons and witnesses; and

c. The nature and location of any injury or damage arising out of the negligent act.

Any claim arising out of such negligent act which is subsequently made against any Certificate Holder and reported to the Company, shall be considered first made at the time such notice was given to the Company.

I. OTHER INSURANCE

PRG 3935 (2/16) ©All rights reserved. Page 4 of 4

This insurance shall be excess over any other insurance, whether provided on an excess, primary, contingent or any other basis, including any self-insurance, except if specifically written to be excess of this Policy.

If there is other insurance which applies to any claim resulting from a negligent act the other insurance shall pay first. This policy applies to the amount of the covered claim which is more than:

1. The Limits of Liability of the other insurance; and

2. The total of all deductibles and self-insured amounts under all such other insurance.

The Company shall not pay more than its Limits of Liability.

All other terms and conditions of the policy remain the same.

This endorsement modifies insurance provided under the following:

91222 (9/16)

118477 (3/15)

POLICYHOLDER NOTICE

Taxes, Assessments and/or Surcharges

The taxes, assessments and/or surcharges shown on the declarations page or any premium schedule are collected on behalf of the applicable State(s) and in accordance with such State’s laws and regulations. The payment of these taxes, assessments and/or surcharges is the responsibility of the Named Insured. In the event the applicable State implements a new tax, assessment and/or surcharge or increases such tax, assessment and/or surcharge during the term of this policy, the Named Insured shall remain responsible for the payment of all amounts due under the policy, including those newly implemented or increased taxes, assessments and/or surcharges.

Any newly implemented or increased taxes, assessments and/or surcharges shall apply on the effective date dictated by the applicable State regardless:

1. Of when the Insurance Company implements the new or increased tax, assessment or surcharge into its systems; or

2. If the Insurance Company recalculates the Named Insured’s premium in accordance with the policy’s terms and conditions as part of a premium audit after the end of the policy period.

ENDORSEMENT

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

PRG 4040 (11/19) ©All rights reserved. Page 1 of 1

This endorsement, effective 12:01 A.M., Forms a part of Policy No.:

COMMERCIAL APPRAISERS AMENDATORY ENDORSEMENT-

PREMIUM AUDIT

This endorsement modifies insurance provided by the policy:

REAL ESTATE APPRAISERS PROFESSIONAL LIABILITY COVERAGE FORM

I. Section V CONDITIONS is amended to include the following additional condition:

Premium Audit

a. The Company will compute all premiums in accordance with our rules and rates.

b. Premium shown on the Certificate Declarations as advance premium is a deposit premium only. At the close of each audit period we will compute the earned premium for that period and send notice to the Named Certificate Holder. The due date for audit and retrospective premiums is the date shown as the due date on the bill. If the sum of the advance and audit premiums paid for the policy period is greater than the earned premium, the Company will return the excess to the Named Certificate Holder.

c. The Named Certificate Holder must keep records of the information we need for premium computation and send us copies at such times as we may request.

All other terms and conditions of the policy remain the same.

Authorized Representative

10/2020

ACCEPTED

ADOT Risk Management

Revised 0���������

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� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � .

I am performing work as an independent contractor for the State of Arizona, �������, for workers' compensation purposes, and therefore, I am not entitled to workers' compensation benefits from the State of Arizona, ���������������������������������������������.

I understand that if I have any employees working for me, I must maintain workers' compensation insurance on them.

Name of Sole Proprietor: _______________________________________________________�

Telephone Number: ___BB______________________B_______________________________

Street Address / P. O. Box: _____________________________________________________

City: ____________________________ State: ________________ ZIP Code: ___________

Signature of Sole Proprietor: __________________________________ Date: _____________

State Agency: ____________________________________________ Agency #: ___________

&RQWUDFW�,GHQWLILFDWLRQ���BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB�

Signature of Agency Contract Administrator: ______________________________________ Date: ______________

Both signatures must be signed and the completed form HPDLOHG to� SOLQVXUDQFH#D]GRD�JRY� An authorized Risk Management Representative will sign your completed form and return it to the agency to be maintained in their records.

Signature of Risk Management Authorized Signer Date

2QFH�WRS�SRUWLRQ�LV�FRPSOHWHG�SOHDVH�HPDLO�WR�\RXU�6WDWH�$JHQF\�UHSUHVHQWDWLYH�IRU�SURFHVVLQJ�

Helmer & Associates

Robert Thomas Helmer

602-493-5621

4409 E Friess Drive

Phoenix AZ 85032

May 11, 2021

DocuSign Envelope ID: 4099E27B-B4B9-41B2-897B-A60376A0ED47

5/11/2021

Arizona Department of Transportation-Procurement

CTR054970