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Industrial Commission of Arizona

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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
  • Reversal Form for Reversing Automated Payment Processing

Reversal Form for Reversing Automated Payment Processing

Instructions

This form must be submitted by the 5th Business Day from the cleared date of the ACH Payment. Once completed, email the form to the GAO AFIS Operations Group at: [email protected].

Sign and Submit Form

GAO State of Arizona ACH Vendor Authorization Form

Related Forms

Insurance Carrier - Quarterly Tax Form
Insurance Carrier - Annual Tax Form 200
Self-Insured Employer - Quarterly Tax Form
Self-Insured Employer - Annual Payroll Report Form
Self-Insured Employer - Annual Medical Report Form
Self-Insured Employer - Annual Injury Report Form
Self-Insured Employer - Annual Hospital Report Form
Workers’ Compensation Liability Form
Self-Provider of Medical Benefits Form
Initial Application for Authority to Self-Insure
Notice of Self-Insurer’s Termination of Self-Insurance Form
Initial Pool Application for Authority to Self-Insure
Reversal Form for Reversing Automated Payment Processing
State of Arizona Substitute W-9 and ACH Vendor Authorization Forms & Instructions

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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