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Get AR RCL317A 2019

STATE OF COUNTY OF ss AFFIDAVIT OF SELF EMPLOYMENT EXEMPTION UNDER THE WORKERS COMPENSATION ACT I Printed Name being first duly sworn upon oath deposes and states the following I am applying for a contractor s license for my company through the State of Arizona s Registrar of Contractors office. I am aware that as a condition of licensure that my company must comply with the Workers Compensation Act. I am self-employed* Therefore I am not an employer subject to the provisions of A. R*S* 23-902. I do not currently and will not in the future employ workers regularly employed in my business or trade under a contract for hire. as an employer. supervision or control that is done in the regular course of my business or trade. I may in my business use the services of an independent contractor to perform work done in the regular course of my business or trade. In the event that I use the services of an independent contractor such use shall be evidenced by a written agreement that the business does not have the authority to supervise or control the actual work of the independent contractor and/or his/her employees. The written agreement will contain a disclosure statement that the A. R*S* 23-902 D. When independent contracting services other than professional services are retained any license see A. R*S* 32-1154 A 10. A. R*S* 23-902 that it will immediately comply with all provisions of the Workers Compensation Act. I am aware that if I and/or my company becomes an employer as previously stated and I/it fails to comply with the Workers Compensation provisions that this is an immediate cause for discipline of the license. 10. I have authority on behalf of my company as its owner partner member manager managing member officer or director to sign this affidavit. Printed Name Signature Applicant Company Name Subscribed and Sworn to before me this day of 20 NOTARY PUBLIC Printed Name RC L 317A 6/14 My Commission Expires. I am aware that as a condition of licensure that my company must comply with the Workers Compensation Act. I am self-employed* Therefore I am not an employer subject to the provisions of A. R*S* 23-902. I do not currently and will not in the future employ workers regularly employed in my business or trade under a contract for hire. I am self-employed* Therefore I am not an employer subject to the provisions of A. R*S* 23-902. I do not currently and will not in the future employ workers regularly employed in my business or trade under a contract for hire. as an employer. supervision or control that is done in the regular course of my business or trade. I may in my business use the services of an independent contractor to perform work done in the regular course of my business or trade. as an employer. supervision or control that is done in the regular course of my business or trade. I may in my business use the services of an independent contractor to perform work done in the regular course of my business or trade. In the event that I use the services of an independent contractor such use shall be evidenced by a written agreement that the business does not have the authority to supervise or control the actual work of the independent contractor and/or his/her employees..

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