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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
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    • Forms
    • Self Service Center
    • ICA Community
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  • Notice of Intent to Suspend Form

Notice of Intent to Suspend Form

Instructions

If a completed Workers’ Annual Report of Income form (Form 110-A) is not returned by the anniversary date of the award for unscheduled permanent disability benefits, the carrier or self-insured employer must notify the injured worker by Notice of Intent to Suspend (Form 110-B) that benefits will be suspended unless the report of earnings is received within 30 days.

If a completed Notice of Intent to Suspend (Form 110-B) is not received at the end of 30 days, the carrier or self-insured employer can suspend the injured worker’s benefits for failure to submit the required Annual Report of Income.  When the Annual Report of Income is received by the carrier or self-insured employer, the injured worker’s benefits are to be reinstated effective as of the date of receipt.

This form is made available for use on this website but is not filed with the Commission.  Carefully follow the directions on the form and return it as instructed.

IMPORTANT:  Any person who knowingly makes a false statement or representation to obtain any compensation, benefit or payment is guilty of a class 6 felony and is subject to up to one and one-half years in prison, a fifty thousand dollar fine and forfeiture of benefits.

Printer-Friendly Form

PDF icon Claims_NoticeOfIntentToSuspend_110B_Master.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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