Arizona Policy Forms
Common use forms for Arizona policyholders.
Arizona Claims
- Workers Report of Injury and Release of Medical Information (Form 41-407)*
- Employer's Report of Injury (Form 101)*
- ScriptAdvisor Workers' Comp First Fill Prescription Card
*You will be redirected to the Arizona Claims Kit for the most current version of this form.
General
- 2023 Mailing Schedule for Permanent Benefit Checks
- 2024 Mailing Schedule for Permanent Benefit Checks
- Annual Drug and Alcohol Program Verification
Policy
- Limited Liability Company or Corporation Statement of Arizona Coverage Election (P-005)
- Employees Notice to Revoke Notice of Rejection – Spanish (P-051s)
- Employees Notice to Revoke Notice of Rejection (P-051)
- Employee Notice of Rejection – Spanish (P-030s)
- Employee Notice of Rejection (P-030)
- ACORD Workers Compensation Application (130)
- Policyholder Change of Address (P-301)
- Policyholder Audit Dispute Request Form (PA-002)
- ERM-14 Form Instructions
- ERM-14 Form – Request for Ownership Information
- Business Name or Entity Change Form (P-201)
- Arizona Sole Proprietor Waiver (P-511)
- Application for Coverage (P-042)