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.