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Industrial Commission of Arizona

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

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  • Home
  • Agency Information
    • About Us
    • Commissioners
    • Director's Office
    • Legislation
      • Arizona Statutes
      • Arizona Rules
    • Meetings
      • 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
  • How Do I
  • Online Services
    • Forms
    • Self Service Center
    • ICA Community
  • Payment Portal
  • OMBUDSMAN
  • Home
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  • Special Fund

Contact Info

Terry Ann Apodaca,
Special Fund Manager


Phoenix Office:
800 W Washington St,
Phoenix, AZ 85007  
Phone: (602) 542-3294
FAX - (602) 542-3696 

General Questions: [email protected]

Special Fund Forms

Special Fund

Special Fund Division

Efficiently providing workers’ compensation benefits to injured workers.

 

Special Fund Claim 570

Claim Management

  • Providing benefits for Uninsured Claimants
  • Continuing medical benefits for pre-1973 workers’ compensation claimants 
  • Continuing workers’ compensation benefits for claimants of insolvent carriers and bankrupt self-insured employers 
  • Workers Supplemental Claim Form 
  • Carrier's Notification of Scheduled Injury Time Loss
  • Workers Supplemental Claim For Compensation

Special Fund Apportionment Vocational 570
APPORTIONMENT & 
VOCATIONAL REHABILITATION

  • Vocational rehabilitation benefits 
  • Partial coverage of workers’ compensation benefits for second injury claims (Apportionments)
  • Apportionment Settlement Letter
  • Vocational Rehabilitation Referral Form

 

 

Special Fund News 570
Agency News

  • 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
  • 06/01/22 ICA Community Update - Upload Confirmation Email
Recent News Archive

Special Fund Forms 570
Forms

  • Workers Supplemental Claim Form
  • Carrier's Notification of Scheduled Injury Time Loss
  • Workers Supplemental Claim For Compensation
  • Apportionment Settlement Letter
  • Vocational Rehabilitation Referral Form

 

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

 

tucson map

Contact Us:

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

 

 

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