Industrial Commission of Arizona
Protection of life, health, safety, and welfare of Arizona's most valuable assets

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Accounting
Form Number Form Name Last Updated
Accounting_6601 Insurance Carrier - Quarterly Tax Form 03/10/17
Accounting_6604 Insurance Carrier - Annual Tax Form 200 12/30/16
Accounting_6605 Self-Insured Employer - Quarterly Tax Form 03/10/17
Accounting_6608 Self-Insured Employer - Annual Payroll Report Form 12/30/16
Accounting_6609 Self-Insured Employer - Annual Medical Report Form 12/30/16
Accounting_6611 Self-Insured Employer - Annual Injury Report Form 12/30/16
Accounting_6613 Self-Insured Employer - Annual Hospital Report Form 12/30/16
Accounting_6620 Workers’ Compensation Liability Form 09/08/16
Accounting_6621 Self-Provider of Medical Benefits Form 09/08/16
Accounting_6622 Initial Application for Authority to Self-Insure 09/08/16
Accounting_6623 Notice of Self-Insurer’s Termination of Self-Insurance Form 09/08/16
Accounting_6624 Initial Pool Application for Authority to Self-Insure 09/08/16
Accounting_6618 GAO State of Arizona ACH Vendor Authorization Form 08/23/16
Accounting_6626 GAO State of Arizona ACH Vendor Information Packet 08/12/16
Accounting_6627 GAO State of Arizona Substitute W-9 & Vendor Authorization Form 08/12/16
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 09/16/16
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 08/12/16
Claims
Form Number Form Name Last Updated
Claims_0446 Request for Hearing Form 09/16/16
Claims_0101 Employer Report of Injury Form 09/16/16
Claims_0102 Worker’s and Physician’s Report of Injury Form 05/19/17
Claims_0407 Worker’s Report of Injury Form 05/19/17
Claims_0121 Request to Change Doctors Form 09/16/16
Claims_0122 Request to Leave State Form 09/16/16
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 08/12/16
Claims_0529 Petition for Rearrangement Form 09/16/16
Claims_0120 Dependent Benefits Claim Form 09/16/16
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 05/08/17
Labor_3304 Public Complaint form Youth Employment and Labor Law Violations 08/12/16
Labor_3325 Minimum Wage Complaint Form 08/12/16
Legal
Form Number Form Name Last Updated
Legal_4401 Uninsured Employer Complaint Form 08/12/16
Legal_4402 Public Records Request Form 03/20/17
Legal_4403 Employers Workers Compensation Insurance Inquiry Response Form 11/03/16
Medical Resource Office
Form Number Form Name Last Updated
MRO_7701 Preauthorization Request and Payer Decision Form 08/12/16
MRO_7702 Request for Administrative Peer Review Form 08/12/16
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