Claims - About New Form 104

Claims Division
About the Revised Notice of Claim Status (Form 104)

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

Phone List of ICA Divisions

January 28, 2016
2016 Revised Notice of Claim Status (Form 104)

Important: This notification supersedes the August 17, 2015 directive.

In keeping with our commitment to the improvement of the workers' compensation system, we have revised the Notice of Claim Status, Form 104. We have clarified the box number three language in response to input and consensus from our stakeholders.

Box number three on Form 104 will now read:

"No temporary compensation paid because the claimant has not currently sustained a temporary disability entitlement attributable to this injury beyond seven consecutive days."

Carriers, Third-Party Administrators and Self-Administered Self-Insured employers may begin using the 2016 Revised Notice of Claim Status, Form 104, immediately and should be fully compliant with the use of the revised Form 104 by March 1, 2016.

Carriers, Third-Party Administrators and Self-Administered Self-Insureds will receive a copy of the revised Form 104 if they are registered to receive correspondence from the Industrial Commission via encrypted email. For those who are not registered to receive correspondence via encrypted email and would like a copy of the new 2016 Revised Notice of Claim Status, Form 104, please contact the Industrial Commission’s Claims Division at (602) 542-4661.

The 2016 Revised Notice of Claim Status, Form 104, is intended to remain consistent with the Arizona Supreme Court's holding in Bell v. Indus. Comm’n, 236 Ariz. 478, 341 P.3d 1149 (2015). As a courtesy, a synopsis of the Bell Opinion is included below.

Bell v. Indus. Comm’n, 236 Ariz. 478, 341 P.3d 1149 (2015).

Synopsis. For the first seventeen months after her industrial accident, the claimant missed work intermittently to attend medical appointments. After undergoing surgery, she missed several months of work. She requested a hearing under A.R.S. § 23-1061(J) when her employer declined to pay her for the work that she missed before her surgery. The ALJ rejected her request for benefits, finding that she had failed to submit any medical evidence that showed she had been taken off work for the period in question. In a memorandum decision, the court of appeals affirmed the award of the Industrial Commission, holding that no temporary partial disability benefits are payable when a claimant has not been totally disabled for at least seven consecutive days.

Issue. Are TPD benefits payable only when a claimant has experienced seven consecutive days of TTD, and if not, must a claimant experience at least seven consecutive days of at least some kind of disability before temporary disability benefits are payable?

Holding. The award of the Industrial Commission is set aside. A.R.S. § 23-1062(B) addresses when compensation is payable, and A.R.S. § 23-1044(A) determines the amount of compensation that may be payable for TPD. The word “disability” in the former statute does not mean inability to perform date-of-injury work, but rather refers to impairment of earning power generally. Read together, the statutes establish that the seven-day waiting period applies to any type of disability, including TPD. Further, any type of disability, including TPD, can establish the waiting period without proof of a prior TTD. In that sense, a claimant may experience a “disability” even though she continues to work. “In sum, we hold that to receive compensation for any type of disability, the claimant must satisfy the waiting period prescribed in § 23-1062(B), which requires proof of seven consecutive calendar days of some type of disability. Those days need not be work days, and the right to compensation does not hinge on time lost from work. We do not address whether the seven consecutive days must immediately follow the actual injury, or whether they may occur during any subsequent, post-injury time frame.”