Worker’s and Physician’s Report of Injury Form


An injured worker must file a workers’ compensation claim in writing with the Commission within one year after the injury occurred. The time for filing a claim begins to run when the injury becomes manifest or when the injured worker knows or in the exercise of reasonable diligence should know that he or she has sustained a compensable work related injury.

An injured worker can make a claim for workers’ compensation benefits by filling out and signing this Worker's and Physician's Report of Injury form at the doctor’s office.  This form has two sections.  The injured worker must complete the first section of the form entitled “Worker’s Report” and sign and date this section of the form.  The physician or the medical provider who treated the injured worker must complete the second section of the form entitled “Physician’s Initial Report” and sign and date this section of the form.

This form must be completed in its entirety, including the name and address of the injured worker’s employer at the time of the alleged injury as well as the address or location of the accident.  Failure to do so may cause a delay in processing.

IMPORTANT: The medical provider completing this form must file it with the Commission within eight (8) days after first rendering treatment.  This form is to be filed with the Commission by mailing the original to the Industrial Commission of Arizona at P.O. Box 19070, Phoenix, AZ   85005.  One (1) copy must also be sent to the injured worker’s employer and to the employer’s workers’ compensation insurance carrier or third-party administrator.