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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
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      • 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
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  • Claims Employee Revocation of Rejection of Terms Form

Claims Employee Revocation of Rejection of Terms Form

Arizona law presumes that all employees have elected to be subject to the provisions of Arizona’s workers’ compensation laws.  However, an employee is permitted to reject the provisions of Arizona’s workers’ compensation laws by completing the Employee’s Notice of Rejection of Terms of the Arizona Workers’ Compensation Law.  See A.R.S. § 23-906(B)-(C).  An employee who has completed and filed with his employer the Employee’s Notice of Rejection of Terms of the Arizona Workers’ Compensation Law make revoke the terms of that Notice by completing the Employee’s Notice to Revoke Rejection of Terms of the Arizona Workers’ Compensation Law.  See A.R.S. § 23-906(B)-(C).  To be valid, the Employee’s Notice to Revoke Rejection of Terms of the Arizona Workers’ Compensation Law must be filled out in duplicate (i.e., two times) and must be filed with the employer prior to the employee sustaining any workplace injuries.  The employer must, in all cases, file a copy of the Notice to Revoke Rejection of Terms of the Arizona Workers’ Compensation Law with the employer’s workers’ compensation insurance carrier.           

Required Forms

Form Name Last Updated
Employee Revocation of Rejection of Terms Form 08/23/16
Employee Revocation of Rejection of Terms Form 08/23/16
Employee Revocation of Rejection of Terms Form 08/23/16

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