Sole_Proprietor_Waiver_MLawing-18985_fully_executed.pdf
PDF 1 MB Posted
- Attached to
- AZ|CTR078889
- Contract number
- CTR078889
- Issued by
- Arizona
About this file
This document is a Sole Proprietor Waiver form from the Arizona Department of Administration's Risk Management Division, specifically applicable to Arizona state agencies, boards, commissions, and universities. The form involves Mercer D. Lawing, a sole proprietor based in Barstow, California, who is performing work as an independent contractor for the Arizona Game and Fish Department under contract number CTR078840.
The waiver document establishes that Mercer D. Lawing is waiving workers' compensation rights and benefits, acknowledging that as a sole proprietor with no employees, he is not entitled to workers' compensation from the State of Arizona. The contract appears to be for independent contractor services, with the sole proprietor maintaining his own workers' compensation insurance if any employees are subsequently hired. The document is signed and dated by the sole proprietor, the agency contract administrator, and includes processing by the Risk Management Division, with relevant dates in September 2025.
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Text version
Contract number changed from: CTR078840 DRAFT in APP-Not Practical to Quote
To: CTR078889 – Competition Impracticable
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: Mercer A. Lawing
Name of Sole Proprietor’s Business: Mercer A Lawing
Street Address/P.O. Box: 940 Olive Court
City: Barstow State: California ZIP Code: 92311
Signature of Sole Proprietor: Signature on file Date:
State Agency: Game & Fish/Dept
Email Address: dbailloux@azgfd.gov
Agency Contract Administrator: Donna Bailloux Date: 9/25/2025
Contract Identification: CTR078840
Debra Davis 18985 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
| Contract number changed to CTR078889 |
| Sole Proprietor Waiver MLawing-18985 s |
| Sole Proprietor Waiver-Mercer Lawing to Risk |
| Sole Proprietor Waiver - 18985 from Risk.pdf |
File details come from the government source that posted it. Updated .