Accounting Initial Application for Authority to Self-Insure Instructions

This application to self-insure is for Arizona employers that have the ability to apply for authorization to self-insure workers’ compensation liability pursuant to A.R.S. § 23-961, et seq.

Arizona employers must also meet the following minimum qualifications to become a self-insured employer:

Minimum qualifications for public employers pursuant to A.A.C. R20-5-1107 (A) include:

  1. Annual payroll in Arizona of at least $2,000,000, and
  2. Total assets of at least $50,000,000.

Minimum qualifications for individual employers pursuant to A.A.C. § R20-5-1107 (B) include:

  1. Engaged in business in Arizona for at least five years prior to the date of the initial application,
  2. Annual Arizona payroll of at least $2,000,000, including the combined payroll of all subsidiary companies that will  be under the self-insurance authority, and
  3. Total assets of at least $50,000,000 or has $10,000,000 in net worth and cash flow ratio of at least .25 (net cash from operating activities divided by current liabilities).

The information submitted in the application is solely for the purpose of procuring a Resolution of Authorization of The Industrial Commission of Arizona which may be given upon satisfactory proof of the employer’s ability to pay compensation and medical benefits related to the incurred employee work injuries.

This application must have an original signature and must be accompanied by a Resolution and/or Statement from Board of Directors authorizing the filing of the application and designating the person given authority to sign the application (signature must be that of a designated Company officer).  If the applicant is a subsidiary company, a completed parent company guaranty form must also accompany the application.

This application must be completed in its entirety.  Failure to do so may cause a delay in processing. It can be submitted to the Industrial Commission Self-Insurance and Tax Office by mail or hand-delivery at the following address:

Industrial Commission of Arizona
Attn: Self-Insurance and Tax Office,
800 W Washington St, Room 301, Phoenix AZ 85007
Phone: (602) 542-1839
FAX: (602) 542-3070