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

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      • All Public Meetings
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      • Self-Insurance and Tax Office
    • Administrative Law Judge (ALJ) Division
    • ADOSH
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      • 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
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    • Resources for Employees
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    • Resources for Medical Providers
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  • Initial Pool Application for Authority to Self-Insure

Initial Pool Application for Authority to Self-Insure

Instructions

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

Sign and Submit Form

Initial Pool Application for Authority to Self-Insure Form

Printer-Friendly Form

PDF icon 6624_Accounting_SelfInsApplicationPool_Master__101517.pdf

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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