Arizona Independent Contractor

Workers' Compensation Acknowledgment

Please read and complete all sections below, then sign at the bottom. A copy of the signed document will be emailed to you.

Party Information

Contractor

Nopal LLC

Independent Contractor Name*

Business Name (if applicable)

ROC License No. (if applicable)

Phone

Email*

Independent Contractor Acknowledgment

I certify that I am performing work as an independent contractor and not as an employee of the Contractor identified above. I understand and acknowledge the following:

I am responsible for determining whether Arizona law requires me or my business to maintain workers' compensation insurance.I am solely responsible for obtaining and maintaining any workers' compensation insurance required by law for myself and any employees I hire.If I hire or supervise any employees, laborers, or subcontractors, I am solely responsible for complying with all applicable federal, state, and local employment and insurance laws.I understand that the Contractor is relying upon my representation that I am an independent contractor.I agree to indemnify and hold harmless the Contractor, Owner, and their agents from any claims, penalties, assessments, or costs arising from my failure to obtain any workers' compensation coverage required by law.I understand that nothing contained in this document creates an employer-employee relationship.

Workers' Compensation Coverage

Please select one:

I maintain workers' compensation insurance.I do not maintain workers' compensation insurance because I believe it is not required for my business under Arizona law.

Certification & Electronic Signature

I certify that the information provided above is true and correct. I understand that providing false information may result in termination of my contract and may subject me to liability under applicable law.

Type your full legal name as your signature*

By typing my name above and checking this box, I agree that my typed name constitutes my legally binding electronic signature on this document, and I consent to conducting this transaction electronically in accordance with the ESIGN Act and UETA.

Privacy notice: the information above (your name, business/license/insurance details, contact info, and signature), along with your IP address and the date/time of signing, is recorded to create and keep a legal record of this acknowledgment, as required for Arizona independent-contractor compliance. A copy of the signed PDF is emailed to you and to Nopal staff. It's otherwise only accessible to Nopal staff and to you, if you view it from a Nopal account under this email address — it is never made public. See our privacy notice for more, or contact human@nopal.build.