File a Claim


How do I file a workers comp claim electronically?

  • You can log in by clicking here if you have previously registered to complete the process of filing the claim online.
  • If you have not previously registered your CopperPoint account and policy you can reference our FAQ’s by clicking here which will explain the registration process and allow you to take advantage of filing the claim online.

What other ways can I file a workers comp claim?

  • If your employee suffers an injury while at work, an Employer's Report of Injury Form (101) must be filed with both CopperPoint and the Industrial Commission of Arizona (ICA).  Filing the industrial injury form begins the claim process.
  • The form can be submitted to CopperPoint via email to or by U.S. mail. The employer should complete the industrial injury form (not the employee). As a service to our policyholder CopperPoint will forward a copy of the form to the ICA on the employer's behalf.
  • The form must be filed within 10 days of the injury, by law.  To provide efficient, appropriate service, and to contain costs, the industrial injury form should accurately be filled out as soon as possible.
  • As of 1/1/15 employers are now also required to report  all in-patient hospitalizations, amputations, or loss of an eye to Occupational and Safety Administration (OSHA) within 24 hours of finding out about the incident.  It is important you notify CopperPoint at 602-631-2300 so the claim process can be initiated.
  • Provide the employee with the ScriptAdvisor Workers' Comp First Fill Prescription Card so they can fill their initial prescription related to the industrial injury.
  • When we receive your Report of Injury Form, CopperPoint will review the information, investigate and make a decision regarding the claim.
  • In the unfortunate event that a fatality occurs, the incident must be reported within 8 hours to Occupational and Safety Administration (OSHA) and to the ICA within 24 HOURS. It is important you notify CopperPoint at 602-631-2300 so the claim process can be initiated.


Medical Provider

If you are a medical provider, please complete the Form 102 and have the injured worker sign it. The completed and signed document should be mailed within eight days of initial treatment. Be sure to fill out the form completely, especially item 14, the first date of treatment, and item 29, work status.

Form 102 can be downloaded here or to request Form 102 via mail, send a request by fax to:

Special Services
Industrial Commission of Arizona
Fax number: 602.542.3104

Please include your physical address, not a Post Office Box number. Medical providers also may request Form 102 at no cost. Please include the number of forms needed (the forms come in packs of 50).

The mailing address for medical bills is scheduled to change, effective October 1, 2018. However, we strongly recommend you use the new address below immediately to ensure the most efficient processing.

Mail Stop: WCS 135801
PO BOX 2979
Clinton, IA 52733-2979 


Nevada C-4 Form: Employee’s Claim for Compensation/Report of Initial Treatment

Must be mailed to:         
CopperPoint Insurance Companies 
P.O. Box 33657
Las Vegas, NV 89133


Injured Worker

  • Immediately notify your employer of the workplace accident, injury or industrial illness. The employer will complete an Employers Report of Injury (Form 101).
  • Ask your employer for a referral to a physician or medical facility, or view CopperPoint's workers' compensation preferred network directory.
  • Upon arrival at the medical facility, complete and sign the Worker's and Physician's Report of Injury form. Your medical provider should have this form available.
  • Ask the physician to immediately send the reports to the Industrial Commission of Arizona and to CopperPoint so your workplace injury compensation claim may be filed.
  • Complete and immediately return all requests for information about your workplace injury claim.
  • Complete the Workers Report of Injury and Release of Medical Information (407) form and return it to CopperPoint via mail or fax.


Injured Worker's Benefits Guide