Sole_Proprietor_Waiver_-_18983_DRA.pdf
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- Attached to
- AZ|CTR078893
- Contract number
- CTR078893
- Issued by
- Arizona
About this file
This document is a Sole Proprietor Waiver form issued by the Arizona Risk Management Division (ADOA-RMD), specifically designed for sole proprietors with no employees working with Arizona state agencies. The document involves Landon Fulkerson of Down Range Archery, located in Kingman, Arizona, who is performing work as an independent contractor for the Arizona Game & Fish Department. The form waives the sole proprietor's rights to workers' compensation benefits under Arizona Revised Statutes § 23-901 and § 23-961(M).
The document does not provide specific details about the contracted goods or services, as the Contract Identification is marked "TBD" (To Be Determined). The waiver explicitly states that if Fulkerson has any employees, he must maintain workers' compensation insurance for them. The document is dated and signed by the sole proprietor, the agency contract administrator Nancie Hays (with contact email nhays@azgfd.gov), and a risk management authorized signer, with dates ranging from 9/25/2025 to 9/26/2025. No pricing terms, contract amounts, or specific service details are outlined in this administrative document.
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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: Landon Fulkerson
Name of Sole Proprietor’s Business: Down Range Archery
Street Address/P.O. Box: 1245 Ames
City: Kingman State: Arizona ZIP Code: 86409
Signature of Sole Proprietor: Signature on file Date:
State Agency: Game & Fish/Dept
Email Address: nhays@azgfd.gov
Agency Contract Administrator: Nancie Hays Date: 9/25/2025
Contract Identification: TBD
Debra Davis 18983 9/26/2025
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
File details come from the government source that posted it. Updated .