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Report workers compensation 2026

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The document is a Self-Insured Injury Report for the Industrial Commission of Arizona, detailing claims related to workplace injuries. It includes instructions for reporting individual claims over and under $5,000 for multiple years (1996-1999), requiring accurate descriptions of injuries and financial details such as amounts paid and outstanding compensation. The report must be certified as true and complete by the reporting individual.

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Click ‘Get Form’ to open the report workers compensation in the editor.
Begin by entering the period covered at the top of the form. This is essential for accurate reporting.
In section (b), provide a brief but detailed description of each claim, including the name, date of injury, and nature of injury. Use as much space as needed for clarity.
For claims over $5,000, list each claim individually in columns (c) through (j), detailing amounts paid and outstanding balances.
For claims $5,000 or less, aggregate totals according to the provided rules and enter them in the appropriate sections.
Finally, certify your report by signing at the bottom and including your title and contact information before submitting.

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