Edit, Download, and Sign the Arizona Sole Proprietor Workers' Compensation Waiver Form
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How do I fill this out?
To fill out this form, provide your business details, sign the waiver, and submit it to the relevant state agency. Ensure all information is accurate before signing. Contact your agency representative for any questions.
How to fill out the Arizona Sole Proprietor Workers' Compensation Waiver Form?
1
Enter your business name and details.
2
Specify the work being performed for the State of Arizona.
3
Sign and date the form as the sole proprietor.
4
Submit the form to your State agency representative.
5
An authorized Risk Management Representative will sign and return the form.
Who needs the Arizona Sole Proprietor Workers' Compensation Waiver Form?
1
Sole proprietors contracting with Arizona state agencies without employees.
2
Independent contractors working for the Arizona government.
3
Freelancers needing to waive their Workers' Compensation rights.
4
Consultants providing services to Arizona state agencies.
5
Small business owners engaged in contracts with the Arizona government.
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1
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Make your changes and update the document.
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What are the instructions for submitting this form?
After completing the form, submit it to your state agency representative. You can email it or use any other submission method specified by the agency. Ensure all necessary signatures are included and that the form is fully completed.
What are the important dates for this form in 2024 and 2025?
The form should be submitted annually, with key dates being January 1, 2024, and January 1, 2025.
What is the purpose of this form?
The purpose of this form is to allow sole proprietors without employees who are contracting with Arizona state agencies to waive their rights to Workers' Compensation coverage. It ensures that these contractors acknowledge their ineligibility for workers' compensation benefits from the State of Arizona. This form is necessary for compliance with Arizona state law and to provide clear documentation for both the contractor and the state agency involved.
Tell me about this form and its components and fields line-by-line.
- 1. Name of Sole Proprietor: The full name of the sole proprietor completing the form.
- 2. Telephone Number: Contact number for the sole proprietor.
- 3. Street Address / P. O. Box: The mailing address for the sole proprietor.
- 4. City: The city of the sole proprietor's address.
- 5. State: The state of the sole proprietor's address.
- 6. ZIP Code: The ZIP code of the sole proprietor's address.
- 7. Signature of Sole Proprietor: Signature of the sole proprietor to validate the form.
- 8. Date: The date when the sole proprietor signs the form.
- 9. State Agency: The state agency for which the sole proprietor is performing work.
- 10. Agency #: The identification number of the state agency.
- 11. Contract Identification: Specific contract identification related to the work being performed.
- 12. Signature of Agency Contract Administrator: Signature of the agency's contract administrator.
- 13. Date: The date when the agency contract administrator signs the form.
- 14. Signature of Risk Management Authorized Signer: Signature of the authorized risk management representative confirming the form is complete.
What happens if I fail to submit this form?
Failure to submit this form may result in non-compliance with Arizona state law and potential legal repercussions. It could also impact your ability to contract with Arizona state agencies.
- Legal Repercussions: Non-compliance with state laws and potential legal action.
- Contracting Issues: Inability to contract with Arizona state agencies until the form is submitted.
How do I know when to use this form?
- 1. Independent Contractors: For sole proprietors performing work as independent contractors for the state.
- 2. Freelancers: Freelancers providing services to Arizona state agencies.
Frequently Asked Questions
How do I fill out this form?
Provide your business details, sign the waiver, and submit it to the relevant state agency.
Who needs to complete this form?
Sole proprietors without employees who are contracting with Arizona state agencies.
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Use the 'Sign' feature to digitally add your signature to the required fields.
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Is digital signature valid on this form?
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What should I do after completing the form?
Submit the completed form to your State agency representative for processing.
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Are there any fees for using PrintFriendly?
No, PrintFriendly offers free tools to edit, sign, and share your PDF forms.
How do I know the form is successfully submitted?
You will receive confirmation from your State agency representative after submission.
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