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Arizona Form Center -

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Form

Description

101.pdf Employer's Report of Injury
Form 104 - Notice of Claim Status - UNAVAILABLE ONLINE. This form can be obtained from The Industrial Commission of Arizona (602) 542-4653
Form 108 - Wage Calculation - UNAVAILABLE ONLINE. This form can be obtained from The Industrial Commission of Arizona (602) 542-4653
wri.pdf Worker's Report of Injury
exposureclaimform.pdf Report of Significant Work Exposure to Bodily Fluids or Other Infectious Material
pr.pdf Petition to Reopen a Claim
nocoverageform.pdf Uninsured Employer Complaint Form
prr.pdf Petition to Rearrange or Readjust Compensation
pubrecreq.pdf Public Records Request Form
doc.pdf Request to Change Doctors
leave.pdf Request to Leave State
rh.pdf Request for Hearing
fatality.pdf Request for Dependents' Benefits - Fatality
110A.pdf Workers Report of Annual Income
110B.pdf Notice of Intent to Suspend
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
pea.pdf Notice of Professional Employer Agreement
AZ-SubstituteW9.pdf State of Arizona Substitute W-9 and Vendor Authorization Form
SoleProprietorStatement.pdf Sole Proprietor/Independent Contractor
securitydeposit.pdf Security Deposit Form Industrial Commission of Arizona
securityrelease.pdf Security Release Form Industrial Commission of Arizona
sii.pdf Application for Authorization to Self-Insure
sip.pdf Application for Authorization to Self-Insure - Pool
bond.pdf Self-Insurance Workers' Compensation Guaranty Bond
term.pdf Notice of Self Insurer Termination
spmed.pdf Self Provider Medical Benefits
LiabilityForm.pdf Workers Compensation Liability
LiabilityFormInstructions.pdf Instructions for Completing the Workers' Compensation Liability Form
poster.pdf POSTER - Work Place Safety (English and Spanish)
workersCompLaw.pdf POSTER - Employer's Compliance with Workers' Compensation Law (English and Spanish)
Poster_BodilyFluids.pdf POSTER - Work Exposure to Bodily Fluids (English and Spanish)
Poster_MRSA.pdf POSTER - Work Exposure to Methicillin-Eesistant Staphylococcus aureus (MRSA), Spinal Meningitis, or Tuberculosis (TB)
ExposureReport.pdf Significant Exposure under the Arizona Workers' Compensation Act
FAQs.pdf BROCHURE - Employers Frequently Asked Questions
IWHandbook.pdf BROCHURE - Workers' Compensation Information for the Injured Worker