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

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  • Agency Information
    • About Us
    • Commissioners
    • Director's Office
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      • Arizona Statutes
      • Arizona Rules
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      • All Public Meetings
      • Commission Meeting Agendas
      • Meeting Minutes
  • Divisions
    • Administration
      • Accounting
      • Human Resources, Special Services and MIS
      • Self-Insurance and Tax Office
    • Administrative Law Judge (ALJ) Division
    • ADOSH
      • Boiler Section
      • Elevator Section
      • Occupational Safety and Health (OSHA / ADOSH)
      • Research & Statistics (BLS)
    • Claims Division
    • Labor Department
    • Legal Division
    • Medical Resource Office (MRO)
    • Special Fund Division
  • News and Events
    • Public Notices
    • News and Events
  • Resources For
    • Resources for Employees
    • Resources for Employers
    • Resources for Insurers
    • Resources for Medical Providers
    • Resources for ICA Community
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  • Claims - Filing a Sole Proprietor/Independent Contractor Statement

Claims - Filing a Sole Proprietor/Independent Contractor Statement

Claims Division
Filing a Sole Proprietor / Independent Contractor Statement

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


Filing a Sole Proprietor / Independent Contractor Statement


Click here to download form :     Sole Proprietor / Independent Contractor Statement (PDF)

This form is for use only by a sole proprietor who is working for an employer who has workers' compensation insurance as permitted by A.R.S. §23-961(P). This form is not valid until signed and dated by both the sole proprietor and insurance carrier. If you have questions concerning this form and what it can be used for, contact your workers' compensation insurance carrier or an attorney.

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Resources for the ICA Community

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

  • 12/20/22 ICA Announces Restructured Ombudsman Team
  • 11/16/22 Notice of Public Hearing – Self Insured Premium Rates – December 15, 2022
Public Notice Archive

Recent News & Events

  • 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
  • 06/01/22 ICA Community Update - Upload Confirmation Email
  • 03/01/22 MRO Online Trainings
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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