This application to self-insure is for Arizona pools that have the ability to apply for Authorization to Self-Insure the payment of workers’ compensation as provided by A.R.S. § 23-961.01, or is a Workers’ Compensation Pool established under A.R.S. § 11-952.01 or A.R.S. § 41-621.01.
The information submitted in the application is solely for the purpose of procuring a Resolution of Authorization of the Industrial Commission of Arizona, which may be given upon satisfactory proof of the pool’s ability to pay compensation and medical benefits related to the pool members’ incurred employee work injuries.
This application must include accurate information regarding the pool’s general information, workers’ compensation claim history, current and prior two years of financial information and classification codes to be used for tax calculation purposes.
This application must be completed in its entirety. Failure to do so may cause a delay in processing. It can be submitted to the Industrial Commission Self-Insurance and Tax Office by mail or hand-delivery at the following address:
Industrial Commission of Arizona
Attn: Self-Insurance and Tax Office,
800 W Washington St, Room 301, Phoenix AZ 85007
Phone: (602) 542-1839
FAX: (602) 542-3070
