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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
    • Data & Statistics
    • 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
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  • Apportionment Settlement Letter

Apportionment Settlement Letter

Instructions

Parties interested in settling the loss of earning capacity involving a claim with approved apportionment should complete the attached form and submit for consideration. The claimant and carrier/self-insured/TPA must contribute to the questions and submit the signed certifications before the claim will be reviewed.  After submission of all required information, Special Fund will perform its evaluation of settlement, taking into consideration of all relevant factors, including Roth credits, prior scheduled credits and any overpayments.  Based upon its evaluation, Special Fund will offer to contribute a certain amount towards settling the matter. Under no circumstances, however, will Special Fund contribute more than 50% of the final settlement amount ultimately negotiated by the parties.  

Sign and Submit Form

Apportionment Settlement Letter Form

Printer-Friendly Form

PDF icon 5527_SpecFund_Apportionment_Settlement_Letter_051018.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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