Darrin DeWitt Arizona 1st Vending Solutions Sole Proprietor Waiver-Executed.pdf
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- Attached to
- Master Agreement AZ|CTR077296
- Contract number
- CTR077296
- Issued by
- Arizona
About this file
This document is a Sole Proprietor Waiver form issued by the Arizona Risk Management Division (ADOA-RMD) specifically for State of Arizona agencies, boards, commissions, and universities utilizing sole proprietors with no employees. The form involves Darrin D. DeWitt, owner of Arizona 1st Vending Solutions, who is performing work as an independent contractor for the Arizona Department of Economic Security under contract CTR077296. The waiver acknowledges that as a sole proprietor, DeWitt is not entitled to workers' compensation benefits from the state agency and understands that if he were to have employees, he would be required to maintain workers' compensation insurance for them.
The document does not provide specific details about the goods or services being contracted, pricing terms, or contract duration beyond the contract identification number. The form is primarily a legal waiver related to workers' compensation requirements under Arizona Revised Statutes § 23-901 and § 23-961(M), allowing a sole proprietor to waive rights to workers' compensation coverage. The form was revised on 04-05-2019 and includes administrative details such as DeWitt's business address in Apache Junction, Arizona, and the contract administrator's information (Cheryl Pellegrino). The document is signed and dated by both the sole proprietor and a Risk Management authorized signer.
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Text version
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: Darrin D. DeWitt
Name of Sole Proprietor’s Business: Arizona 1st Vending Solutions
Street Address/P.O. Box: 3400 South Ironwood Drive, Lot 283
City: Apache Junction State: Arizona ZIP Code: 85120
Signature of Sole Proprietor: Signature on file Date:
State Agency: Economic Security, Dept Of
Email Address: jleung@azdes.gov
Agency Contract Administrator: Cheryl Pellegrino Date: 9/3/2025
Contract Identification: CTR077296
James Abdo 18908 9/4/2025
Signature of Risk Management Authorized Signer / Request # Date
File details come from the government source that posted it. Updated .