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Industrial Commission of Arizona
Protection of life, health, safety, and welfare of Arizona's workforce

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  • Claims - About Forms 110A and 110B

Claims - About Forms 110A and 110B

Claims Division
About Forms 110A and 110B

Ruby Tate, Claims Manager
Email: [email protected]
Phoenix: 800 W Washington St, Phoenix AZ 85007 - Phone: (602) 542-4661
Tucson: 2675 East Broadway, Tucson AZ 85716 - Phone: (520) 628-5181
FAX (use for either office): (602) 542-3373

Click for Phone List of ICA Divisions

 

About Forms 110A and 110B


The Commission has revised two forms, the Worker’s Annual Report of Income, Form 110-A, and the Notice of Intent to Suspend, Form 110-B. The Commission revised these forms to include the statement mandated by House Bill 2331, 52nd Legislature, First Regular Session, (A.R.S. § 23-1028(D)), and for minor non-substantive changes.

The statement that has been added to these forms reads: “Any person who knowingly makes a false statement or representation to obtain any compensation, benefit or payment is guilty of a class 6 felony and is subject to up to one and one half years in prison, a fifty thousand dollar fine and forfeiture of benefits. By my signature below, I am applying for all benefits to which I may be entitled and I swear that the statements made on this application are true, correct and complete to the best of my knowledge.”

The requirement that reports of income include the statement is effective on July 3, 2015. Both revised forms Form 110-A and 110-B contain a revision date of 6/2015 in the lower left-hand corner and the use of all previous versions of the forms should be discontinued. Questions regarding the new forms should be directed to the Claims Division at (602) 542-4661.

Both of these forms may be downloaded directly from this website:

 

Click on a link below to obtain . . .
adobe_pdf.png   Form 110A: Annual Report of Income


adobe_pdf.png   Form 110B: Notice of Intent to Suspend

 

 

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Wage Information

  • 2023 AMW Statutory Max - $5,393.37 
  • 2023 Minimum Wage - $13.85 per hour
  • 2022 AMW Statutory Max - $5,161.12 
  • 2022 Minimum Wage - $12.80 per hour 

Job Opportunities at the ICA

Job Opportunities at the ICA

Public Notices

  • 05/26/23 Notice of Public Hearing Regarding 2023-2024 Physicians’ and Pharmaceutical Fee Schedule on June 29, 2023
  • 04/24/23 Notice of Public Hearing Regarding One-Half Percent Assessment Under A.R.S § 23-1065(F) on May 25, 2023
Public Notice Archive

Recent News & Events

  • 05/19/23 ICA Claims Seminar - Registration Now Open
  • 02/01/23 New Medical Resource Office Trainings Available
  • 12/06/22 Rule 20-5-1534 Self-Insurance Q&A
  • 09/15/22 2023 Minimum Wage Increase
  • 06/09/22 Cancer Claim Reporting and MFCR Training
Recent News Archive

Official Website of the State of Arizona

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Contact Us:

Phoenix Office
800 W. Washington Street
Phoenix AZ 85007
602-542-4661

 

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Contact Us:

Tucson Office
2675 E. Broadway Blvd
Tucson AZ 85716
520-628-5188

 

 

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