Forms

Forms

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Claims
Form Number Form Name Last Updated
Claims_0113 Employee Rejection of Terms Form 08/12/16
Claims_110A Annual Report of Income Form 08/12/16
Claims_110B Notice of Intent to Suspend Form 08/12/16
Claims_0114 Employee Revocation of Rejection of Terms Form 08/23/16
Claims_0124 Bodily Fluids Work Exposure Form 09/16/16
Claims_0123 Professional Employer Agreement Form 09/16/16
Claims_0529 Petition for Rearrangement Form 06/07/19
Claims_0102 Worker’s and Physician’s Report of Injury Form 12/06/19
Claims_0122 Request to Leave State Form 07/21/23
Claims_0101 Employer Report of Injury Form 07/21/23
Claims_0446 Request for Hearing Form 07/21/23
Claims_0407 Worker’s Report of Injury Form 07/21/23
Claims_0121 Request to Change Doctors Form 07/21/23
Claims_0120 Dependent Benefits Claim Form 07/21/23
Claims_0528 Petition to Reopen Form 07/21/23
Special Fund
Form Number Form Name Last Updated
SpecFund_5525 Carrier's Notification of Scheduled Injury Time Loss 08/12/16
SpecFund_5413 Workers Supplemental Claim Form 413 08/12/16
SpecFund_5526 Workers Supplemental Claim For Compensation 01/18/17
SpecFund_5528 Vocational Rehabilitation Referral 06/07/19
SpecFund_5527 Apportionment Settlement Letter 02/01/21
Legal
Form Number Form Name Last Updated
Legal_4403 Employers Workers Compensation Insurance Inquiry Response Form 07/12/17
Legal_4404 Petition for Attorney’s Fees 03/08/18
Legal_4401 Public Records Request Form 04/01/20
Legal_4402 Uninsured Employer Complaint Form 09/03/20
Accounting
Form Number Form Name Last Updated
Accounting_6620 Workers’ Compensation Liability Form 12/28/17
Accounting_6621 Self-Provider of Medical Benefits Form 12/28/17
Accounting_6622 Initial Application for Authority to Self-Insure 12/28/17
Accounting_6623 Notice of Self-Insurer’s Termination of Self-Insurance Form 12/28/17
Accounting_6624 Initial Pool Application for Authority to Self-Insure 12/28/17
Accounting_6618 Reversal Form for Reversing Automated Payment Processing 12/24/18
Accounting_6604 Insurance Carrier - Annual Tax Form 200 01/17/23
Accounting_6608 Self-Insured Employer - Annual Payroll Report Form 01/17/23
Accounting_6611 Self-Insured Employer - Annual Injury Report Form 01/17/23
Accounting_6609 Self-Insured Employer - Annual Medical Report Form 01/20/23
Accounting_6613 Self-Insured Employer - Annual Hospital Report Form 01/20/23
Accounting_6627 State of Arizona Substitute W-9 and ACH Vendor Authorization Forms & Instructions 03/31/23
Accounting_6601 Insurance Carrier - Quarterly Tax Form 03/31/23
Accounting_6605 Self-Insured Employer - Quarterly Tax Form 03/31/23
Administrative Law Judge (ALJ)
Form Number Form Name Last Updated
ALJ_8801 Interested Party Workers’ Compensation Document Submission 03/07/18
Medical Resource Office
Form Number Form Name Last Updated
MRO_7711 Medical Treatment Preauthorization Form 09/27/18
Labor
Form Number Form Name Last Updated
Labor_3305 Earned Paid Sick Time Claim Form 02/25/22
Labor_3307 EPST/Minimum Wage Retaliation Claim Form 02/25/22
Labor_3306 Youth Labor Complaint Form 02/25/22
Labor_3304 Payment Compliance Complaint Form 02/25/22
Labor_3303 Unpaid Wage Claim Form 09/12/23
Labor_3325 Minimum Wage Claim Form 09/12/23
ADOSH
Form Number Form Name Last Updated
ADOSH_2222 Request for Boiler Repair Form 03/20/23
ADOSH_2223 Request for Boiler Certificate Form 03/20/23
ADOSH_2212 Report a Fatality or Severe Injury Form 07/21/23
ADOSH_2213 Notice of Alleged Safety or Health Hazards Form 07/21/23
ADOSH_2215 Discrimination / Whistleblower Complaint Form 07/21/23
ADOSH_2221 Application for Permit to Install or Alter Elevator Form 07/21/23
ADOSH_2217 Consultation Request Form 07/21/23
ADOSH_2218 ADOSH Training Request Form 07/21/23
ADOSH_2227 Elevator Inspection (PEI) New Application 07/21/23
ADOSH_2232 Boiler Inspector (PBI) Renewal Application 07/21/23
ADOSH_2224 Compliance Assistance Request Form 07/21/23
ADOSH_2225 VPP Pre-Screening Form 07/21/23
ADOSH_2226 SHARP Application Form 07/21/23