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.