Sole Proprietor / Independent Contractor Forms - www4 - Northern ...

Although the State form notes that it should be submitted to the Arizona Department of
Administration, if you are with NAU, please send the competed and signed form to
Property and Liability Insurance Services (PLIS) at P.O. Box 4067 or scan and email it
to Laura.Maldonado@nau.edu. Once PLIS has reviewed and obtained authorized signature,
the form will be sent to the Arizona Department of Administration.
This letter is to provide you w ith information to assist you in completing one of the
attached forms. Please, review the tw o sections below to help you determine if you
should complete the Independent Contractor Form or the Sole Proprietor Form.
1. Independent Contractor: A.R.S. 23-902(C)(D)
C. A person engaged in w ork for a business, and w ho w hile so engaged is
independent of that business in the execution of the work and not subject to the rule or
control of the business for w hich the w ork is done, but is engaged only in the performance
of a definite job or piece of work, and is subordinate to that business only in effecting a
result in accordance with that business design, is an independent contractor.
D. A business that uses the services of an independent contractor and the
independent contractor may prove the existence of an independent contractor relationship
by executing a w ritten agreement that complies w ith this subsection. The w ritten
agreement shall evidence that the business does not have the authority to supervise or
control the actual w ork of the independent contractor or the independent contractor's
employees. A w ritten agreement executed in compliance w ith this subsection creates a
rebuttable presumption of an independent contractor relationship betw een the parties if the
w ritten agreement contains a disclosure statement that the independent contractor is not
entitled to w orkers' compensation benefits from the business. Unless the rebuttable
presumption is overcome, no premium may be collected by the carrier on payments by the
business to the independent contractor if a fully completed w ritten agreement that satisfies
the requirements of this subsection is submitted to the carrier. The w ritten agreement shall
be dated and contain the signatures of both parties and, unless otherw ise provided by law,
shall state that the business:
1. Does not require the independent contractor to perform w ork exclusively for the
business. This paragraph shall not be construed as conclusive evidence that an
individual w ho performs services primarily or exclusively for another person is an
employee of that person.
2. Does not provide the independent contractor w ith any business registrations or
licenses required to perform the specific services set forth in the contract.
3. Does not pay the independent contractor a salary or hourly rate instead of an
amount fixed by contract.
4. Will not terminate the independent contractor before the expiration of the
contract period, unless the independent contractor breaches the contract or violates
the law s of this state.
5. Does not provide tools to the independent contractor.
6. Does not dictate the time of performance.

7. Pays the independent contractor in the name appearing on the w ritten
agreement.
8. Will not combine business operations w ith the person performing the services
rather than maintaining these operations separately.
2. Sole Proprietor: A.R.S. 23-961(P)
P. Notw ithstanding section 23-901, paragraph 6, subdivision (i), a sole proprietor
may w aive the sole proprietor's rights to w orkers' compensation coverage and benefits if
both the sole proprietor and the insurance carrier of the employer subject to this chapter
for w hich the sole proprietor performs services sign and date a w aiver that is substantially
in the follow ing form:
I am a sole proprietor, and I am doing business as (name of sole proprietor). I am
performing w ork as an independent contractor for (name of employer). I am not the
employee of (name of employer) for w orkers' compensation purposes, and,
therefore, I am not entitled to w orkers' compensation benefits from (name of
employer). I understand that if I have any employees w orking for me, I must
maintain workers' compensation insurance on them.
_________________________ _________________________
Sole proprietor
Date
_________________________ _________________________
Insurance Carrier
Date
Thank you for your help w ith this matter. If you have any questions, please contact your
legal counsel or the Arizona Industrial Commission’s Legal Department at 602-542-5781.

Janice K. Brewer
Governor
Brian C. McNeil
Director
NOTE:
ARIZONA DEPARTMENT OF ADMINISTRATION
RISK MANAGEMENT DIVISION
100 NORTH FIFTEENTH AVENUE • SUITE 301
PHOENIX, ARIZONA 85007
(602) 542-2182
INDEPENDENT CONTRACTOR AGREEMENT
THIS FORM APPLIES ONLY TO THE STATE OF ARIZONA AGENCIES, BOARDS,
COMMISSIONS, UNIVERSITIES UTILIZING INDEPENDENT CONTRACTORS. THIS FORM DOES NOT,
HOWEVER APPLY TO EMPLOYERS IN THE CONSTRUCTION INDUSTRY THAT USE A CONTRACTOR. A
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE OR A SOLE PROPRIETOR WAIVER MUST
BE OBTAINED IN THOSE INSTANCES.
This is a written agreement under the compulsory Workers' Compensation laws of the State of
Arizona, A.R.S. § 23-901 (et. seq.), and specifically A.R.S. § 23-902 (C), (D), that an independent
contractor relationship exists between the parties signed below. The parties agree that the
"independent contractor" is independent of the "business" in the execution of the work and not
subject to the rule or control of the "business" but is engaged only in the performance of a definite
job or piece of work and is subordinate to the "business" only in effecting a result in accordance
with that "business" design. The parties also agree that the "business" does not have the authority
to supervise or control the actual work of the "independent contractor" or the "independent
contractor's" employees. Furthermore, it is understood and agreed that the "independent
contractor" or the "independent contractor's" employees are not entitled to workers' compensation
benefits from the "business".
The written agreement shall be null and void and create no presumption of an independent
contractor relationship if the consent of either party is obtained through misrepresentation, false
statements, fraud or intimidation, coercion or duress.
WE THE UNDERSIGNED AGREE THAT THE BUSINESS:
• Does not require the independent contractor to perform work exclusively for the business.
This paragraph shall not be construed as conclusive evidence that an individual who
performs services primarily or exclusively for another person is an employee of that person.
• Does not provide the independent contractor with any business registrations or licenses
required to perform the specific services set forth in the contract.
• Does not pay the independent contractor a salary or hourly rate instead of an amount fixed
by contract.
• Will not terminate the independent contractor before the expiration of the contract period,
unless the independent contractor breaches the contract or violates the laws of this state.
• Does not provide tools to the independent contractor.
• Does not dictate the time of performance.
• Pays the independent contractor in the name appearing on the written agreement.
Revised 11-01-2012

• Will not combine business operations with the person performing the services rather than
maintaining these operations separately.
NAME OF INDEPENDENT
CONTRACTOR: _____________________________________________________________
ADDRESS / P.O. BOX: _______________________________________________________
CITY: __________________________________, STATE: ____________ ZIP: __________
SIGNATURE OF
INDEPENDENT CONTRACTOR: ______________________________DATE: ___________
STATE OF ARIZONA
AGENCY:
AGENCY#
ADDRESS:
CITY/STATE:
ZIP:
SIGNATURE OF AGENCY
CONTRACT ADMINISTRATOR: ______________________________ DATE: ____________
CONTRACT IDENTIFICATION: __________________________________________________
BOTH SIGNATURES MUST BE SIGNED AND THE COMPLETED FORM SUBMITTED TO:
ARIZONA DEPARTMENT OF ADMINISTRATION
RISK MANAGEMENT SECTION - INSURANCE UNIT
100 NORTH 15 th AVENUE, SUITE #301
PHOENIX, AZ 85007
An authorized Risk Management Representative will sign your completed form and return it to the
agency to be maintained in their records.
Signature of Risk Management Authorized Signer
Date
Revised 02-09-2011

Janice K. Brewer
Governor
Brian C. McNeil
Director
ARIZONA DEPARTMENT OF ADMINISTRATION
RISK MANAGEMENT DIVISION
100 NORTH FIFTEENTH AVENUE - SUITE 301
PHOENIX, ARIZONA 85007
(602) 542-2182
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, 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(P) , 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 Here) , for workers' compensation purposes, and therefore, I am not
entitled to workers' compensation benefits from the State of Arizona, (Enter State Agency Here) .
I understand that if I have any employees working for me, I must maintain workers' compensation insurance on
them.
Name of Sole Proprietor
Telephone Number
Street Address / PO Box
City State Zip Code
Signature of Sole Proprietor: _________________________________
Date
State Agency Agency #
Signature of Agency
Contract Administrator: _________________________________
Contract Identification:
Date
Both signatures must be signed and the completed form submitted to: State of Arizona,
Department of Administration, Risk Management Division, Insurance Unit, 100 North 15 Avenue,
Suite 301, Phoenix, Arizona 85007. An authorized Risk Management Representative will sign
your completed form and return it to the agency to be maintained in their records.
Signature of Risk Management Authorized Signer
Date