Arizona Workers’ Comp Forms & Resources
Arizona Required Postings and Forms
EMPLOYERS® Claim Kit (click here to download)
Please print and post the following notices, both in English and Spanish, in a conspicuous location frequented by employees, such as the break room, lunch room or time clock. If you have multiple business locations, be sure to post the notices at each location.
- Notice to Employees Re: Arizona Workers’ Compensation Law
- Notice to Employees Re: Work Exposure to Bodily Fluids
- Notice to Employees Re: Work Exposure to Methicillin-Resistant Staphylococcus Aureus (MRSA), Spinal Meningitis, or Tuberculosis (TB): This notice must be displayed immediately next to the Notice to Employees Re: Work Exposure to Bodily Fluids
The following forms need to be completed and submitted to EMPLOYERS when a work-related injury occurs:
- Form ICA-04-0101 Employer’s Report of Industrial Injury. As soon as you have been notified of a work-related injury, please fill out this form and submit it to EMPLOYERS. This form must be completed within 10 days from notice of an accident. Fatalities must be reported within 24 hours. You must use this form to notify EMPLOYERS of every work-related injury or disease suffered by an employee, regardless of severity.
- Form ICA-41-100 Report of Significant Work Exposure to Bodily Fluids. This form is completed by you and must be signed by the employee. You should keep the original and provide a copy to EMPLOYERS. This copy will serve as our notice that your employee experienced a significant work-related exposure to bodily fluids of another individual .
- First Fill Form. This form provides your employees with basic information about our Pharmacy Benefit Program, including such things as the phone number to call to locate a First Fill participating pharmacy. When your employee becomes injured, please print and complete this form and provide it to your injured employee. Your employee will need to provide this completed form along with the prescription for his/her work-related injury or illness to the pharmacist. Using this form will help enable quick authorization for your employee’s initial medication and ensure that the initial prescription is provided at no cost to the injured employee.
- Wage Statement. This form enables us to calculate the correct compensation that may be owed to an injured employee. Please complete the form and submit it to EMPLOYERS within five days after your knowledge of any accident that has caused your employee to be disabled for more than seven scheduled work calendar days.
- Accident Investigation Report. This basic accident form should be completed by the employee’s supervisor/manager as soon after the accident as possible. Please send the report to the following EMPLOYERS address as soon as it has been completed by the supervisor/manager: EMPLOYERS Claim Department, P.O. Box 32036, Lakeland, FL 33802-2036. You should keep a copy on file for your records.
More Arizona Workers’ Comp Resources
- Off-Site Transitional Duty Program - Helping Your Injured Employees Get Back to Work
A successful transition back to work relies on the collaborative efforts of the manager/supervisor, the injured employee and their adjuster. As a manager/supervisor, learn what you can do to help facilitate a successful return to work.