An employer currently authorized by the Industrial Commission of Arizona to self-insure its incurred workers’ compensation liability must complete this form when terminating its self-insurance authority pursuant to A.A.C. R20-1136 (A). Completion of this form must be filed with the division 30 days before the effective date of termination of self-insurance.
Proof of workers’ compensation insurance coverage must accompany this form. This ensures the employer is in compliance with the requirements of A.R.S. § 23-961, et seq., to cover claims of the self-insured employer that:
- Are pending at the time the self-insured employer terminates self-insurance; and
- Occur after the effective date of the termination of self-insurance.
This form must be completed in its entirety. Failure to do so may cause a delay in processing. It can be filed with the Industrial Commission Self-Insurance and Tax Office by mail or hand-delivery at the following address:
Industrial Commission of Arizona
Attn: Self-Insurance and Tax Office,
800 W Washington St, Room 301, Phoenix AZ 85007
Phone: (602) 542-1839
FAX: (602) 542-3070