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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
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  • Carrier's Notification of Scheduled Injury Time Loss

Carrier's Notification of Scheduled Injury Time Loss

Instructions

Insurance carriers, third-party administrators and self-insured employers must complete this injured worker profile form when a scheduled injury results in the injured worker’s inability to return to date of injury work.  It must be completed in its entirety including pertinent medical information so that eligibility for vocational rehabilitation can be determined.

Printer-Friendly Form

PDF icon SpecFunds_Carriers Notification of Scheduled Injury_Master.pdf

Related Forms

Workers Supplemental Claim Form 413
Carrier's Notification of Scheduled Injury Time Loss
Workers Supplemental Claim For Compensation
Apportionment Settlement Letter
Vocational Rehabilitation Referral

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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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