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WORKERS’ COMPENSATION WAIVER FORM

WORKERS COMPENSATIONWAIVERFORMT hefollowingisawrittenwaiverunderthecompu lsoryWorkers CompensationlawsoftheStateofArizona, 23-901( ),andspecifically, 23-961(1),thatprovidesthataSoleProprieto rmaywaivehis/herrightstoWorkers :(PleasePrint CompanyNameorNameofSoleProprietor/Indepe ndentContractor)Iamperformingworkasacomp any/soleproprietor/independentcontractor forAgroLand&CattleCo., ,neithermyselfnotanyofmystaffareemployee sofAgroLand& CattleCo., ;Therefore,forworkers compensationpurposes,neitherInoranyofmys taffareentitledtoworkers compensationbenefitsfromAgroLand& CattleCo., ,Imustmaintainworkers :_____SocialSecurityNumber:_____ :_____City:_____State:_____ZipCode:Signa ture:_____Date:_____Acopyofthiswaiverwil lbekeptonfileandwillbeavailableforauditp urposes.

WORKERS’ COMPENSATION WAIVER FORM 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(1), that provides that a Sole Proprietor may waive his/her rights to Workers’ Compensation coverage and benefits.

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