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

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      • Self-Insurance and Tax Office
    • Administrative Law Judge (ALJ) Division
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      • Elevator Section
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      • Research & Statistics (BLS)
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    • Legal Division
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    • Special Fund Division
  • News and Events
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    • News and Events
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    • Resources for Employees
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  • Worker’s and Physician’s Report of Injury Form

Worker’s and Physician’s Report of Injury Form

Instructions

An injured worker must file a workers’ compensation claim in writing with the Commission within one year after the injury occurred. The time for filing a claim begins to run when the injury becomes manifest or when the injured worker knows or in the exercise of reasonable diligence should know that he or she has sustained a compensable work related injury.

An injured worker can make a claim for workers’ compensation benefits by filling out and signing this Worker's and Physician's Report of Injury form at the doctor’s office.  This form has two sections.  The injured worker must complete the first section of the form entitled “Worker’s Report” and sign and date this section of the form.  The physician or the medical provider who treated the injured worker must complete the second section of the form entitled “Physician’s Initial Report” and sign and date this section of the form.

This form must be completed in its entirety, including the name and address of the injured worker’s employer at the time of the alleged injury as well as the address or location of the accident.  Failure to do so may cause a delay in processing.

IMPORTANT: The medical provider completing this form must file it with the Commission within eight (8) days after first rendering treatment.  This form is to be filed with the Commission by mailing the original to the Industrial Commission of Arizona at P.O. Box 19070, Phoenix, AZ   85005.  One (1) copy must also be sent to the injured worker’s employer and to the employer’s workers’ compensation insurance carrier or third-party administrator.

Printer-Friendly Form

PDF icon 0102 Claims_102_RevisitSpecialCase_Master_063017b.pdf

Related Forms

Request for Hearing Form
Employer Report of Injury Form
Worker’s and Physician’s Report of Injury Form
Worker’s Report of Injury Form
Request to Change Doctors Form
Request to Leave State Form
Annual Report of Income Form
Notice of Intent to Suspend Form
Petition to Reopen Form
Petition for Rearrangement Form
Dependent Benefits Claim Form
Professional Employer Agreement Form
Bodily Fluids Work Exposure Form
Employee Rejection of Terms Form
Employee Revocation of Rejection of Terms Form

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