Search | Industrial Commission of Arizona

List of Insurance Carriers Authorized to Write Workers' Compensation

… CARRIERS AUTHORIZED TO WRITE WORKERS' COMP INSURANCE IN ARIZONA … INSURANCE COMPANY (312) 580-1900 17221 HOMESITE INSURANCE COMPANY (617) 832-1300 38849 …

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Data and Statistics

… 1451 from the 55th Legislature, the Industrial Commission of Arizona will be revising and … first responder cancer claims pursuant to A.R.S. §23-971. Sections … Data and Statistics …

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GAO State of Arizona ACH Vendor Information Packet

… from the cleared date of the ACH Payment. Once completed, email the form to the GAO AFIS Operations Group at: …

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Request to Leave State Form

Instructions

An injured worker may not leave the state for a period exceeding two weeks, (15 days or more), while the need for active medical treatment continues, without the written approval of the Commission. This form may be used to request approval to leave the state. It must be completed in its entirety including the reason for the request. Failure to state the reason for the request may cause a delay in processing.

The Commission will issue an award either approving or disapproving the request to leave the state. If approved, the effective date which grants permission for the injured worker to leave the state is the date on which the injured worker filed this request.

E-sign Electronic Submission Form

Request to Leave State Form

Printable Form

Claims_RequestToLeaveState_Master_0.pdf

Authorized Self-Insured Employers

… Self-Insurer Idenfication # Self-Insurer Name (Company subsidiaries included but not listed) … 7/1/1997 SI00100 Arizona, State of (pursuant to A.R.S. §23-962) 7/1/1983 SI00259 Banner …

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