Forms

Forms

Please Note: The use of these forms requires the user to have installed Adobe Reader, version 8.0 or later. It is recommended that the user obtain (or upgrade to) the latest available Reader version offered by Adobe Systems, Inc., the creator. To download Adobe Reader directly from the Internet, simply click on the link below.

If necessary, please download Adobe Reader.

Static forms need to be printed and completed manually.

Interactive forms may be opened online or downloaded to your PC and completed at a later time when offline. Interactive forms enable the user to enter information directly into the forms. Forms which require a signature or other type of manual authentication need to be printed, signed or authenticated, then transmitted to this office.
Accounting
Form Number Form Name Last Updated
Accounting_6601 Insurance Carrier - Quarterly Tax Form 02/22/19
Accounting_6604 Insurance Carrier - Annual Tax Form 200 01/23/19
Accounting_6605 Self-Insured Employer - Quarterly Tax Form 02/22/19
Accounting_6608 Self-Insured Employer - Annual Payroll Report Form 01/22/19
Accounting_6609 Self-Insured Employer - Annual Medical Report Form 01/14/19
Accounting_6611 Self-Insured Employer - Annual Injury Report Form 01/22/19
Accounting_6613 Self-Insured Employer - Annual Hospital Report Form 01/14/19
Accounting_6620 Workers’ Compensation Liability Form 12/28/17
Accounting_6621 Self-Provider of Medical Benefits Form 12/28/17
Accounting_6622 Initial Application for Authority to Self-Insure 12/28/17
Accounting_6623 Notice of Self-Insurer’s Termination of Self-Insurance Form 12/28/17
Accounting_6624 Initial Pool Application for Authority to Self-Insure 12/28/17
Accounting_6618 Reversal Form for Reversing Automated Payment Processing 12/24/18
Accounting_6627 State of Arizona Substitute W-9 and ACH Vendor Authorization Forms & Instructions 12/24/18
Administrative Law Judge (ALJ)
Form Number Form Name Last Updated
ALJ_8801 Interested Party Workers’ Compensation Document Submission 03/07/18
ADOSH
Form Number Form Name Last Updated
ADOSH_2212 Report a Fatality or Severe Injury Form 08/12/16
ADOSH_2213 Notice of Alleged Safety or Health Hazards Form 09/16/16
ADOSH_2215 Discrimination Complaint Form 07/18/19
ADOSH_2217 Consultation Request Form 08/12/16
ADOSH_2218 ADOSH Training Request Form 08/12/16
ADOSH_2219 ADOSH Standards Book Order Form 08/12/16
ADOSH_2221 Application for Permit to Install or Alter Elevator Form 08/12/16
ADOSH_2222 Request for Boiler Repair Form 08/12/16
ADOSH_2223 Request for Boiler Certificate Form 07/12/19
Claims
Form Number Form Name Last Updated
Claims_0446 Request for Hearing Form 06/07/19
Claims_0101 Employer Report of Injury Form 06/07/19
Claims_0102 Worker’s and Physician’s Report of Injury Form 12/06/19
Claims_0407 Worker’s Report of Injury Form 06/07/19
Claims_0121 Request to Change Doctors Form 06/07/19
Claims_0122 Request to Leave State Form 06/07/19
Claims_110A Annual Report of Income Form 08/12/16
Claims_110B Notice of Intent to Suspend Form 08/12/16
Claims_0528 Petition to Reopen Form 06/07/19
Claims_0529 Petition for Rearrangement Form 06/07/19
Claims_0120 Dependent Benefits Claim Form 06/07/19
Claims_0123 Professional Employer Agreement Form 09/16/16
Claims_0124 Bodily Fluids Work Exposure Form 09/16/16
Claims_0113 Employee Rejection of Terms Form 08/12/16
Claims_0114 Employee Revocation of Rejection of Terms Form 08/23/16
Labor
Form Number Form Name Last Updated
Labor_3303 Claims for Unpaid Wages 06/13/19
Labor_3304 Public Complaint form Youth Employment and Labor Law Violations 12/28/17
Labor_3305 Earned Paid Sick Time Complaint Form 06/13/19
Labor_3325 Minimum Wage Complaint Form 06/13/19
Legal
Form Number Form Name Last Updated
Legal_4401 Public Records Request Form 02/13/19
Legal_4402 Uninsured Employer Complaint Form 07/12/17
Legal_4403 Employers Workers Compensation Insurance Inquiry Response Form 07/12/17
Legal_4404 Petition for Attorney’s Fees 03/08/18
Medical Resource Office
Form Number Form Name Last Updated
MRO_7711 Medical Treatment Preauthorization Form 09/27/18
Special Fund
Form Number Form Name Last Updated
SpecFund_5413 Workers Supplemental Claim Form 413 08/12/16
SpecFund_5525 Carrier's Notification of Scheduled Injury Time Loss 08/12/16
SpecFund_5526 Workers Supplemental Claim For Compensation 01/18/17
SpecFund_5527 Apportionment Settlement Letter 01/05/18
SpecFund_5528 Vocational Rehabilitation Referral 06/07/19