Skip to main content

Industrial Commission of Arizona

0
  • 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
Industrial Commission of Arizona Logo
Industrial Commission of Arizona
Protection of life, health, safety, and welfare of Arizona's workforce

Follow Industrial Commission of Arizona on:

Main menu

  • 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 Notice of Intent to Suspend Form

Claims Notice of Intent to Suspend Form

If a completed Workers’ Annual Report of Income form (Form 110-A) is not returned by the anniversary date of the award for unscheduled permanent disability benefits, the carrier or self-insured employer must notify the injured worker by Notice of Intent to Suspend (Form 110-B) that benefits will be suspended unless the report of earnings is received within 30 days.

If a completed Notice of Intent to Suspend (Form 110-B) is not received at the end of 30 days, the carrier or self-insured employer can suspend the injured worker’s benefits for failure to submit the required Annual Report of Income.  When the Annual Report of Income is received by the carrier or self-insured employer, the injured worker’s benefits are to be reinstated effective as of the date of receipt.

This form is made available for use on this website but is not filed with the Commission.  Carefully follow the directions on the form and return it as instructed.

IMPORTANT:  Any person who knowingly makes a false statement or representation to obtain any compensation, benefit or payment is guilty of a class 6 felony and is subject to up to one and one-half years in prison, a fifty thousand dollar fine and forfeiture of benefits.

Required Forms

Form Name Last Updated
Notice of Intent to Suspend Form 08/12/16
Notice of Intent to Suspend Form 08/12/16
Notice of Intent to Suspend Form 08/12/16

Official Website of the State of Arizona

phoenix map

Contact Us:

Phoenix Office
800 W. Washington Street
Phoenix AZ 85007
602-542-4661

 

tucson map

Contact Us:

Tucson Office
2675 E. Broadway Blvd
Tucson AZ 85716
520-628-5188

 

 

Arizona State Seal

Footer Nav

  • Statewide Policies
  • Site Map
  • The Ombudsman-Citizens Aide helps citizens to resolve ongoing issues with State Agencies