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Industrial Commission of Arizona

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Industrial Commission of Arizona Logo
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
  • Home
  • Claims Dependent Benefits Claim Form

Claims Dependent Benefits Claim Form

In case of an injury causing death,  the surviving spouse and/or surviving dependents of the deceased worker must file a claim with the Commission (“Claim for Dependent’s Benefits - Fatality”) to secure workers’ compensation benefits and burial expenses. This form may be used to file a dependents claim.  It must be completed in its entirety.  Failure to do so may cause a delay in processing.

Required Forms

Form Name Last Updated
Dependent Benefits Claim Form 06/07/19
Dependent Benefits Claim Form 06/07/19
Dependent Benefits Claim Form 06/07/19

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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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