Workers' Compensation

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.

Instructions

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 La Paz, Mohave, Navajo, Pinal, and Santa Cruz Counties,
please This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

For Workers’ Compensation Claims for Member Counties Apache, Cochise, Gila, Graham, Greenlee, and Yavapai,
please This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

OTHER WC FORMS

Please visit the Industrial Commission of Arizona for more information.