Arizona Counties Insurance Pool is pleased to provide our Member Counties
with online tools that enhance our ability to work together efficiently. 

The forms below are available to download and fill out on your computer. You can then email the form or print and mail the form to the desired location.


  • Step 1: Download the form to your desktop by clicking the “download form” button.
  • Step 2: Read and follow the instructions page found on the first page of the download.
  • Step 3: Fill out the form using Adobe Acrobat. (Download Adobe Reader)
  • Step 4: Return form per the instructions found on the first page of the downloaded form. If form needs to be returned to ACIP:

For Workers’ Compensation Claims for Member Counties Apache, Cochise, Gila, Graham, Greenlee, La Paz, Mohave, Navajo, Santa Cruz and Yavapai, please e-mail here.
For Workers’ Compensation Claims for Member Counties Pinal and Yuma, please e-mail here.

Downloads: (Will Open In New Window)

Supervisor’s Report of Injury
Employer’s Report of Industrial Injury
First Fill DefinitiRx
Work Exposure to Bodily Fluids

Other WC Forms

WC Worker’s Report of Injury
WC Claims Request To Leave State
WC Claims Petition To Reopen
WC Claims Request To Change Doctors
Travel Form

For more information, please go to the Industrial Commission of Arizona