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Industrial Commission of Arizona

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

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Main menu

  • 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
  • Home
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Forms

Forms

Please Note: The use of these forms requires the user to have installed Adobe Reader, version 8.0 or later. It is recommended that the user obtain (or upgrade to) the latest available Reader version offered by Adobe Systems, Inc., the creator. To download Adobe Reader directly from the Internet, simply click on the link below.

If necessary, please download Adobe Reader.

Static forms need to be printed and completed manually.

Interactive forms may be opened online or downloaded to your PC and completed at a later time when offline. Interactive forms enable the user to enter information directly into the forms. Forms which require a signature or other type of manual authentication need to be printed, signed or authenticated, then transmitted to this office.
Accounting
Form Number Form Name Last Updated
Accounting_6601 Insurance Carrier - Quarterly Tax Form 03/16/23
Accounting_6604 Insurance Carrier - Annual Tax Form 200 01/17/23
Accounting_6605 Self-Insured Employer - Quarterly Tax Form 03/16/23
Accounting_6608 Self-Insured Employer - Annual Payroll Report Form 01/17/23
Accounting_6609 Self-Insured Employer - Annual Medical Report Form 01/20/23
Accounting_6611 Self-Insured Employer - Annual Injury Report Form 01/17/23
Accounting_6613 Self-Insured Employer - Annual Hospital Report Form 01/20/23
Accounting_6618 Reversal Form for Reversing Automated Payment Processing 12/24/18
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_6627 State of Arizona Substitute W-9 and ACH Vendor Authorization Forms & Instructions 01/13/20
ADOSH
Form Number Form Name Last Updated
ADOSH_2212 Report a Fatality or Severe Injury Form 03/20/23
ADOSH_2213 Notice of Alleged Safety or Health Hazards Form 03/20/23
ADOSH_2215 Discrimination / Whistleblower Complaint Form 03/20/23
ADOSH_2217 Consultation Request Form 03/20/23
ADOSH_2218 ADOSH Training Request Form 03/20/23
ADOSH_2221 Application for Permit to Install or Alter Elevator Form 03/20/23
ADOSH_2222 Request for Boiler Repair Form 03/20/23
ADOSH_2223 Request for Boiler Certificate Form 03/20/23
ADOSH_2224 Compliance Assistance Request Form 06/30/21
ADOSH_2225 VPP Pre-Screening Form 06/25/21
ADOSH_2226 SHARP Application Form 06/13/22
ADOSH_2227 Elevator Inspection (PEI) New Application 03/20/23
ADOSH_2232 Boiler Inspector (PBI) Renewal Application 03/20/23
Administrative Law Judge (ALJ)
Form Number Form Name Last Updated
ALJ_8801 Interested Party Workers’ Compensation Document Submission 03/07/18
Claims
Form Number Form Name Last Updated
Claims_0101 Employer Report of Injury Form 06/07/19
Claims_0102 Worker’s and Physician’s Report of Injury Form 12/06/19
Claims_0113 Employee Rejection of Terms Form 08/12/16
Claims_0114 Employee Revocation of Rejection of Terms Form 08/23/16
Claims_0120 Dependent Benefits Claim Form 06/07/19
Claims_0121 Request to Change Doctors Form 06/07/19
Claims_0122 Request to Leave State Form 06/07/19
Claims_0123 Professional Employer Agreement Form 09/16/16
Claims_0124 Bodily Fluids Work Exposure Form 09/16/16
Claims_0407 Worker’s Report of Injury Form 03/23/22
Claims_0446 Request for Hearing Form 06/07/19
Claims_0528 Petition to Reopen Form 06/07/19
Claims_0529 Petition for Rearrangement Form 06/07/19
Claims_110A Annual Report of Income Form 08/12/16
Claims_110B Notice of Intent to Suspend Form 08/12/16
Labor
Form Number Form Name Last Updated
Labor_3303 Unpaid Wage Claim Form 02/25/22
Labor_3304 Payment Compliance Complaint Form 02/25/22
Labor_3305 Earned Paid Sick Time Claim Form 02/25/22
Labor_3306 Youth Labor Complaint Form 02/25/22
Labor_3307 EPST/Minimum Wage Retaliation Claim Form 02/25/22
Labor_3325 Minimum Wage Claim Form 02/25/22
Legal
Form Number Form Name Last Updated
Legal_4401 Public Records Request Form 04/01/20
Legal_4402 Uninsured Employer Complaint Form 09/03/20
Legal_4403 Employers Workers Compensation Insurance Inquiry Response Form 07/12/17
Legal_4404 Petition for Attorney’s Fees 03/08/18
Medical Resource Office
Form Number Form Name Last Updated
MRO_7711 Medical Treatment Preauthorization Form 09/27/18
Special Fund
Form Number Form Name Last Updated
SpecFund_5413 Workers Supplemental Claim Form 413 08/12/16
SpecFund_5525 Carrier's Notification of Scheduled Injury Time Loss 08/12/16
SpecFund_5526 Workers Supplemental Claim For Compensation 01/18/17
SpecFund_5527 Apportionment Settlement Letter 02/01/21
SpecFund_5528 Vocational Rehabilitation Referral 06/07/19

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Resources for the ICA Community

Wage Information

  • 2023 AMW Statutory Max - $5,393.37 
  • 2023 Minimum Wage - $13.85 per hour
  • 2022 AMW Statutory Max - $5,161.12 
  • 2022 Minimum Wage - $12.80 per hour 

Job Opportunities at the ICA

Job Opportunities at the ICA

Public Notices

  • 12/20/22 ICA Announces Restructured Ombudsman Team
  • 11/16/22 Notice of Public Hearing – Self Insured Premium Rates – December 15, 2022
Public Notice Archive

Recent News & Events

  • 02/01/23 New Medical Resource Office Trainings Available
  • 12/06/22 Rule 20-5-1534 Self-Insurance Q&A
  • 09/15/22 2023 Minimum Wage Increase
  • 06/09/22 Cancer Claim Reporting and MFCR Training
  • 06/01/22 ICA Community Update - Upload Confirmation Email
Recent News Archive

Official Website of the State of Arizona

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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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