Arizona Workers' Compensation Forms: Complete Guide to Required Documents

Table of Contents#

1. Key Arizona Workers' Compensation Forms
   • Employer's Report of Injury (Form 101)
   • Worker's and Physician's Report of Injury (Form 102)
   • Worker's Report of Injury (Form 407)
   • Request for Hearing (Form 446)
   • Petition to Reopen (Form 528)
2. Common Mistakes to Avoid When Filing
3. How to Access and Submit Forms
4. Conclusion
5. References

Key Arizona Workers' Compensation Forms#

Employer's Report of Injury (Form 101)#

Purpose: Notifies the Industrial Commission of Arizona (ICA) and the employer's insurance carrier of a work-related injury or illness. Who Files: Employers (or their representatives, such as HR managers or third-party administrators). Deadline: Within 10 days of learning about the injury or illness (A.R.S. § 23-908(G)). Failing to file on time may result in penalties, including fines or loss of insurance coverage. Key Information Required:

• Employee details (name, address, SSN, job title, hire date).
• Injury details (date, time, location, cause, nature of injury/illness).
• Medical treatment provided (if any), including the name of the treating provider.
• Employer details (name, address, insurance carrier information). Submission: As of July 2025, Form 101 must be submitted online only through the ICA's webform system. Fax and mail submissions are no longer accepted. After submitting, the filer receives an email requesting a digital signature, followed by a confirmation email with the option to download a copy for records.

Worker's and Physician's Report of Injury (Form 102)#

Purpose: A combined form used to document both the employee's account of the injury and the medical provider's initial assessment. This form serves as the official claim filing with the ICA when completed and signed by both parties. Who Files: The injured worker completes the first section ("Worker's Report"), and the treating physician or medical provider completes the second section ("Physician's Initial Report"). Deadline: The medical provider must file this form with the ICA within 8 days after first rendering treatment for the work-related injury (A.R.S. § 23-1061). Key Information Required:

• Worker's section: Personal information, employer details, date and description of how the injury occurred.
• Physician's section: Diagnosis (ICD-10 codes), treatment plan, work restrictions (e.g., "no heavy lifting," "light duty only"), and estimated time off work. Submission: Mail the original to the Industrial Commission of Arizona, P.O. Box 19070, Phoenix, AZ 85005. One copy must also be sent to the injured worker's employer and to the employer's workers' compensation insurance carrier or third-party administrator.

Worker's Report of Injury (Form 407)#

Purpose: Allows an injured employee to formally file a workers' compensation claim with the ICA. Submitting a completed Form 407 to the ICA constitutes the legal filing of a workers' compensation claim. Who Files: The injured employee (or their representative, such as a spouse or attorney). Deadline: Within 1 year of the injury or the date the employee knew (or should have known) the injury was work-related (A.R.S. § 23-1061(A)). Late claims may be denied. Key Information Required:

• Personal information (name, address, contact details, SSN).
• Employment details (employer name, job title, dates of employment).
• Injury details (date, time, location, how it happened, symptoms).
• Medical history related to the injury (treating doctors, hospitals, treatments received).
• A statement confirming the injury is work-related. Submission: Submit to the ICA by mail to P.O. Box 19070, Phoenix, AZ 85005-9070 or through the ICA Community online webform system. Employees should keep a copy for their records.

Request for Hearing (Form 446)#

Purpose: Initiates a formal dispute resolution process with the ICA if there's a disagreement over a claim (e.g., denied benefits, disputed closure, or medical treatment). Who Files: Employees, employers, or insurance carriers. Deadline: Varies by issue (e.g., 90 days from receiving a notice of claim status, 60 days from a claim denial). Key Information Required:

• Claim number and parties involved (employee, employer, insurance carrier).
• Basis for the dispute (e.g., "Claim was wrongfully denied," "Benefits were improperly terminated").
• Supporting evidence (medical records, witness statements, etc.). Submission: File with the ICA through the online webform system or by mail. A hearing will be scheduled before an Administrative Law Judge (ALJ), who will issue a ruling.

Petition to Reopen (Form 528)#

Purpose: Allows an injured worker to request reopening of a previously closed claim when there is a new, additional, or previously undiscovered temporary or permanent condition related to the original injury. Who Files: The injured employee. Deadline: A petition to reopen is a lifetime right—there is no time limit, as long as the condition is new or previously undiscovered. Key Information Required:

• Claim number and employee details.
• Description of the new or changed medical condition.
• A current medical report from a physician supporting the reopening. Submission: File with the ICA through the online webform system or by mail.

Common Mistakes to Avoid When Filing#

• Missing Deadlines: Late filings (e.g., Form 101 after 10 days) can lead to claim denials or employer penalties.
• Incomplete Information: Forms with missing details (e.g., unclear injury dates or medical provider info) will be rejected, delaying benefits.
• Using Outdated Forms: The ICA periodically updates forms. Always download the latest version from the ICA website to avoid rejection.
• Failing to Notify All Parties: Always submit copies to the ICA, insurance carrier, and other relevant parties (e.g., employee for Form 101).
• Ignoring Disputes: Employees who skip filing Form 446 to challenge a denial may lose their right to appeal.
• Not Filing Form 102: Medical providers must file Form 102 with the ICA within 8 days of first treatment. Failure to do so can delay the employee's claim.

How to Access and Submit Forms#

Arizona workers' compensation forms are available for free on the Arizona Industrial Commission (ICA) website (azica.gov/online-services/forms). Most forms can be filled out online through the ICA Community webform system or downloaded and completed offline. Submission methods include:

• Online: The ICA Community portal allows secure electronic submission for faster processing. Form 101 (Employer's Report of Injury) must be submitted online.
• Mail: Industrial Commission of Arizona, P.O. Box 19070, Phoenix, AZ 85005-9070.
• Note: Fax submissions are no longer accepted for most forms as of 2025.

Conclusion#

Navigating Arizona's workers' compensation system requires careful attention to required forms. Employers must promptly report injuries using Form 101, employees must file claims on time using Form 407 or Form 102, and medical providers must document treatments accurately by completing their section of Form 102 within 8 days. By understanding these forms and avoiding common mistakes, you can ensure compliance, protect employee rights, and streamline the claims process.

References#

• Arizona Industrial Commission. (n.d.). Forms. https://www.azica.gov/online-services/forms
• Arizona Revised Statutes (A.R.S.) § 23-1061 (Notice of accident; claim for compensation; filing deadlines).
• A.R.S. § 23-908 (Injury reports by employer and physician; 10-day employer reporting requirement).