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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
  • Uninsured Employer Complaint Form

Uninsured Employer Complaint Form

Instructions

Arizona law requires that all employers have workers’ compensation coverage for their employees.  See A.R.S. § 23-961.  Any member of the public may use this form to report an employer that does not have workers’ compensation coverage, as required by law.  Please provide as much information as possible.  

You may submit an Uninsured Employer Complaint Form in the following ways:

Electronically (preferred):
Via the Commission’s Website (http://www.azica.gov/forms)

In-person or by mail:                 
Industrial Commission of Arizona
c/o Legal Division, Investigations Section
800 West Washington Street
Phoenix, Arizona 85007

By Fax:
(602)-364-1395

You may also report an employer that does not have workers’ compensation coverage by calling the Commission’s Complaint Hotline:  (602)-542-5766.

Sign and Submit Form

Uninsured Employer Complaint Form

Printer-Friendly Form

PDF icon Legal_Uninsured Employer Complaint form_Master_20200831.pdf

Related Forms

Public Records Request Form
Uninsured Employer Complaint Form
Employers Workers Compensation Insurance Inquiry Response Form
Petition for Attorney’s Fees

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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