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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
  • Dependent Benefits Claim Form

Dependent Benefits Claim Form

Instructions

In case of an injury causing death,  the surviving spouse and/or surviving dependents of the deceased worker must file a claim with the Commission (“Claim for Dependent’s Benefits - Fatality”) to secure workers’ compensation benefits and burial expenses. This form may be used to file a dependents claim.  It must be completed in its entirety.  Failure to do so may cause a delay in processing.

Sign and Submit Form

Dependent Benefits Claim Form

Printer-Friendly Form

PDF icon 0120 Claims_DependentBenefitsClaim_Master_051517.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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Phoenix AZ 85007
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