Application to Self-Insure Pool for Workers' Compensation - Arizona: Fill out & sign online

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Does Arizona require workers compensation insurance?

Under Arizona law, it is mandatory for employers to secure workers compensation insurance for their employees. Workers compensation is a no fault system in which an injured employee is entitled to receive benefits for an industrial injury, no matter who caused the job-related accident.

How do I apply for workers compensation in Arizona?

A claim is made either by filling out and signing a Workers and Physicians Report of Injury at the doctors office or by obtaining a Workers Report of Injury (use download link directly above to obtain report form) from the ICA, and filing either report with the ICA. Both of these reports constitute a claim form.

What is the waiting period for workers compensation in AZ?

Temporary Total Benefits Min: $200/month Max: $5161.12 per month effective 1/1/2022 7 day waiting period with retro benefits paid if more than 14 days lost. Benefits paid bi-weekly. Unlimited benefits. No TTD due if worker on salary continuation at 100% of wages.

What is the name of the Arizona approved claim form for workers compensation?

Workers Report of Injury Form.

What is the workers Compensation Act in Arizona?

Under Arizona law, it is mandatory for employers to secure workers compensation insurance for their employees. Workers compensation is a no fault system in which an injured employee is entitled to receive benefits for an industrial injury, no matter who caused the job-related accident.

How to apply for workers compensation in Arizona?

Claims - Filing a Claim A claim is made either by filling out and signing a Workers and Physicians Report of Injury at the doctors office or by obtaining a Workers Report of Injury (use download link directly above to obtain report form) from the ICA, and filing either report with the ICA.

What is the name of the Arizona approved claim form for workers compensation?

Workers Report of Injury Form.

What is a 102 form in Arizona?

Form 102 is required by the Industrial Commission of Arizona for a Physicians Initial Report of Injury. The report must be made using or by attaching a report to the form.

Application to Self-Insure Pool for Workers' Compensation - Arizona 2025

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