Darrin_DeWitt_Arizona_1st_Vending_Solutions_Sole_Proprietor_Waiver-Executed.pdf
PDF 120 KB Posted
- 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 applicable to State of Arizona agencies utilizing sole proprietors with no employees. The document 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 form waives workers' compensation coverage for the sole proprietor while acknowledging that any potential employees would require workers' compensation insurance.
The document does not provide specific details about the goods or services being contracted, though it establishes a contractual relationship between the sole proprietor and the state agency effective through September 3, 2025. The waiver is executed in compliance with Arizona Revised Statutes § 23-901 and § 23-961(M), which allow sole proprietors to waive workers' compensation rights. The form was revised on 04-05-2019 and includes signatures from the sole proprietor, an agency contract administrator, and a risk management authorized signer to validate the workers' compensation waiver.
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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 .