Self-Insurance Forms
Self-Insurance fORMS
Phoenix: 800 W Washington St, Phoenix AZ 85007 - Phone: (602) 542-4661
Tucson: 2675 East Broadway, Tucson AZ 85716 - Phone: (520) 628-5181
FAX (use for either office): (602) 542-3373
Click for Phone List of ICA Divisions
| Form Name | Last Updated |
|---|---|
| Initial Application for Authority to Self-Insure | 07/20/23 |
| New Pool Member Application | 07/20/23 |
| Notice of Termination of Self-Insurance | 07/20/23 |
| Parent Company Guaranty | 07/20/23 |
| Custody Agreement | 07/20/23 |
| Application to Self Administer | 07/20/23 |
| Notice of Termination of Pool Member's Self-Insurance | 07/20/23 |
| Statutory Deposit Agreement | 07/20/23 |
| Request for Waiver of Security | 07/20/23 |
| Workers' Compensation Guaranty Bond | 07/20/23 |
| Self-Insurance Renewal Application | 07/20/23 |
