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

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  2. Forms
  3. Self-Insurer Request For Extension To File Tax Forms

Self-Insurer Request for Extension to File Tax Forms

E-sign Electronic Submission Form

Self-Insurer Request for Extension to File Tax Forms

Printable Form

Initial Application for Authority to Self-Insure Form.pdf

Related Forms

Form Name
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-Insurer Request for Extension to File Tax Forms
Self-Insured Employer - Annual Injury Report Form
Self-Insured Employer - Annual Hospital Report Form
Reversal Form for Reversing Automated Payment Processing
State of Arizona Substitute W-9 and ACH Vendor Authorization Forms & Instructions
Official Seal of the State of Arizona

Contact

Phoenix Office
800 W. Washington Street
Phoenix, AZ 85007

 

Tucson Office
2675 E. Broadway Blvd
Tucson AZ 85716

 

Phoenix: (602) 542-4661
Tucson: (520) 628-5188

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