Arizona Form Center -
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Form |
Description |
| 101.pdf | Employers Report of Injury Form 101 |
| Form 104 - Notice of Claim Status - UNAVAILABLE ONLINE Multi page carbon form. This form can be obtained from The Industrial Commission of Arizona (602) 542-4653 | |
| Form 108 - Wage Calculation - UNAVAILABLE ONLINE Multi page carbon form. This form can be obtained from The Industrial Commission of Arizona (602) 542-4653 | |
| wri.pdf | Worker's Report of Injury |
| pr.pdf | Petition to Reopen Based on New, Additional or Previously Undiscovered Disability or Condition |
| prr.pdf | Petition for Rearrangement or Readjustment of Compensation |
| doc.pdf | Request to Change Doctors |
| leave.pdf | Request to Leave State |
| rh.pdf | Request for Hearing |
| fatality.pdf | Claim for Dependents Benefits - Fatality |
| 0110a.pdf | Worker's Annual Report of Income |
| pea.pdf | Professional Employer Agreement Notice |
| haz.pdf | Notice of Alleged Health or Safety Hazards |
| consult.pdf | Request for Consultation |
| dis.pdf | Discrimination Form (English) |
| dis-sp.pdf | Discrimination Form (Spanish) |
| sii.pdf | Application for Authorization to Self-Insure - Individual |
| sip.pdf | Application for Authorization to Self-Insure - Pool |
| LiabilityForm.pdf | Workers Compensation Liability |
| LiabilityFormInstructions.pdf | Instructions For Completing The Workers’ Compensation Liability Form |
| bond.pdf | Self-Insurance Workers Compensation Guaranty Bond Form |
| spmed.pdf | Self Provider Medical Benefits |
| term.pdf | Notice of Self Insurer Termination |
| poster.pdf | POSTER - Work Place Safety (English and Spanish) |
| workersCompLaw.pdf | POSTER - Workers Compensation Law English and Spanish) |
| Poster_BodilyFluids.pdf | POSTER - Work Exposure to Bodily Fluids |
| Poster_BodilyFluidsSp.pdf | POSTER - Work Exposure to Bodily Fluids (Spanish) |
| Poster_MRSA.pdf | POSTER - Work exposure to methicillin-resistant staphylococcus aureus (MRSA), spinal meningitis, or tuberculosis (TB) |
| ExposureReport.pdf | Report Of Significant Work Exposure To Bodily Fluids Or Other Infectious Material |
| SoleProprietorStatement.pdf | Sole Proprietor/Independent Contractor |
| RejectionofTerms.pdf | Employee’s Notice Of Rejection Of Terms Of The Arizona Workers’ Compensation Law |
| RevokeRejectionofTerms.pdf | Employee’s Notice To Revoke Rejection Of Terms Of The Arizona Workers’ Compensation Law |
| FAQs.pdf | BROCHURE - Employers Frequently Asked Questions |
| IWHandbook.pdf | BROCHURE - Workers' Compensation Information for the Injured Worker |