Crowthers_Sole_Proprietor_Waiver.pdf

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